The Role of Maintenance Treatment in Advanced Non–Small-Cell Lung Cancer: Reality or Early Second Line?

The Potential of Combined Immunotherapy and Antiangiogenesis for the Synergistic Treatment of Advanced NSCLC

Over the past few years, there have been considerable advances in the treatments available to patients with metastatic or locally advanced NSCLC, particularly those who have progressed during first-line treatment. Some of the treatment options available to patients are discussed here, with a focus on checkpoint inhibitor immunotherapies (nivolumab and pembrolizumab) and antiangiogenic agents (bevacizumab, ramucirumab, and nintedanib). It is hypothesized that combining immunotherapy with antiangiogenic treatment may have a synergistic effect and enhance the efficacy of both treatments. In this review, we explore the theory and potential of this novel treatment option for patients with advanced NSCLC. We discuss the growing body of evidence that proangiogenic factors can modulate the immune response (both by reducing T-cell infiltration into the tumor microenvironment and through systemic effects on immune-regulatory cell function), and we examine the preclinical evidence for combining these treatments. Potential challenges are also considered, and we review the preliminary evidence of clinical efficacy and safety with this novel combination in a variety of solid tumor types.

Identifying Subsequent Therapies in Patients with Advanced Non-Small Cell Lung Cancer and Factors Associated with Overall Survival

STUDY OBJECTIVES

To identify subsequent therapies used after first-line therapies in patients with advanced non-small cell lung cancer (NSCLC), compare overall survival (OS) associated with subsequent therapies, and evaluate factors associated with OS in these patients.

METHODS

The study was a retrospective cohort analysis of patients with advanced NSCLC (stage IIIB/IV) who were initiated on first-line therapy from January 1, 2008, through September 30, 2013, and afterward given subsequent chemotherapy (index date). Patients had to be 18 years or older at the time of diagnosis of advanced NSCLC. Patients were followed from the index date until one of the following end points: end of the study (September 30, 2014), disenrollment from the health plan, or death-whichever came the earliest. The primary outcome was OS. Kaplan-Meier curves and Cox proportional hazard models were used to analyze OS and evaluate the factors associated with OS.

RESULTS

The analysis included 1280 patients on subsequent therapies. The most common subsequent therapies were pemetrexed (284 patients [22%]), erlotinib (216 patients [17%]), and docetaxel (139 patients [11%]). Patients from the singlets group had a lower OS at 6.3 months compared with all other groups: pemetrexed based, combination of pemetrexed and bevacizumab based, bevacizumab based, doublets, and tyrosine kinase inhibitors (p<0.0001). Factors associated with greater OS included age younger than 65 years, female gender, and a longer time between initiation of first and subsequent therapies. Factors associated with a reduction in OS were pemetrexed-based or singlet regimens for subsequent therapy, diagnosis of squamous histology, and a higher number of adverse events prior to subsequent therapy.

CONCLUSION

We found that a subsequent therapy consisting of singlets is associated with reduced OS compared with other chemotherapy groups. Patient characteristics such as female gender, age younger than 65 years, diagnosis of nonsquamous histology, and/or a longer time frame between initiation of first-line and subsequent chemotherapy are associated with longer survival.