Lung cancer - non-small cell; NSCLC
Chemotherapy is the use of drugs given by mouth or injection to destroy cancer cells that may have spread beyond the tumor. Until recently, there has been some doubt about the effectiveness of chemotherapy for lung cancer. A major analysis of 52 trials supported its use, particularly with platinum-based regimens, and with the combination of supportive care.
Most chemotherapy regimens use platinum compounds, either cisplatin (Platinol) or carboplatin (Paraplatin). The preferred regimen uses two drugs -- one of which is a platinum-based drug. Combinations may include paclitaxel (Taxol) and carboplatin or cisplatin. This regimen can also include gemcitabine, docetaxel, or vinblastine (vindesine or vinorelbine). There do not seem to be any significant differences in effectiveness among these regimens. The gemcitabine and vinorelbine combination might be a good option for patients who cannot tolerate platinum compounds.
Chemotherapy for lung cancer may have reached its peak. Still, investigative chemotherapeutic drugs may yet improve response. Many experts are pinning their hope on agents called biologic response modifiers, such as gefitinib (Iressa). To date, however, they have not achieved better results than standard platinum-based chemotherapies. Gefitinib (Iressa), a second-line therapy for non-small cell lung cancer, is now available only for a limited group of patients. These patients have benefited from gefitinib in the past, or they are enrolled in a clinical study with the drug. While this medicine initially showed great promise in clinical trials, results from a newer study failed to show that it prolonged survival in advanced lung cancer patients who failed other treatments.
Erlotinib (Tarceva) is in the same medication class as gefitinib. It is approved for patients with locally advanced or metastatic non-small cell lung cancer who have failed one type of chemotherapy treatment in the past (it is a second-line treatment). Unlike gefitinib, erlotinib shows survival and progression-free benefits compared to placebo. However, it should not be combined with platinum-based chemotherapy.
Pemetrexed (Alimta). Pemetrexed, known as an anti-folate, is a new drug for first-line treatment of advanced nonsquamous non-small cell lung cancer, in combination with cisplatin. The drug targets a number of enzymes that play a role in how cancer cells increase. Pemetrexed does have some serious toxic effects, but they can be significantly reduced with folic acid and vitamin B12 supplements.
Chemotherapy treatments are usually performed in an outpatient setting. They are given in regular cycles for several months. Researchers are still investigating how many chemotherapy cycles to administer in late-stage cancers, the timing of those cycles, and the sequences of the drugs. For instance, a three- or four-course cycle may achieve the same survival times and better quality of life than the standard of six or more course cycles. However, changing even one day in a drug sequence can sometimes significantly affect the outcome. Such fine-tuning of chemotherapy regimens is likely to have the most effect on patients with advanced-stage disease, which requires more tailored treatment than early-stage disease.
Side effects of chemotherapy treatments are common, and they are more severe with higher doses. Side effects increase over the course of treatment. Some studies suggest that side effects can be reduced by giving the drugs for shorter durations, without losing the cancer-killing effects.
Common side effects include the following:
These side effects are nearly always temporary. Most patients are able to continue with their normal activities for all but perhaps 1 or 2 days per month.
Serious complications of chemotherapy can also occur, and vary depending on the specific drugs. These complications include:
Second-line chemotherapy is used for patients whose cancers have come back after the first round of chemotherapy. Several of these agents listed below have prolonged survival for patients with non-small cell lung cancer. Unfortunately, this survival benefit is usually only a matter of several months. Efforts are under way to identify which patients are more likely to benefit from these therapies. Because platinum-based agents are most often used first, they are not beneficial for second-line therapy.
Commonly used second-line agents include:
Particularly for more aggressive or advanced cancers, different combinations of surgery, chemotherapy, and radiation therapy may be tried. These include:
Severe inflammation in the esophagus is the most common severe side effect of the radiation and chemotherapy combination. There is also a very high risk of serious infections, including pneumonia, herpes zoster, and cytomegalovirus. Long-term antibiotic therapy may be needed.
Although patients over 70 may suffer more from toxic effects than younger patients, studies now suggest that they can achieve survival rates with combined treatments that are equal to those in younger patients.
There are many painkilling medications available. Research shows that aggressive pain relief can help patients better manage cancer treatment symptoms. For example, reducing pain in elderly cancer patients may markedly lower their fatigue levels, and improve other symptoms as well.
Opioids are the most potent painkillers. The correct use of these strong medications is very important for reaching acceptable pain relief and preventing a toxic response. For example, the long-lasting version of oxycodone (OxyContin) must be swallowed whole. Chewing, inhaling, or injecting it can create a deadly overdose.
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