Tailor Treament to the Patient
Gold standard anticancer agent is difficult to find, says Swiss oncologist
Despite warnings about the dangers of smoking, the number of people in the country who get lured by tobacco smoking continues to rise. Inevitably, the number of people who fall ill of lung malignancies also grows by the year. The lung remains the leading cancer site among men-and third among women-in the country.
Dr. Matti Aapro, director of Switzerland's Clinique de Genolier-Institut Multidisciplinaire d'Oncologie, recently visited the country to speak about new treatment options in the management of lung cancer. In an exclusive MEDICAL OBSERVER interview, Aapro spoke about recent breakthroughs in the detection and management of lung cancer.
Of the lung malignancies, the nonsmall cell type is the most common, comprising between 75 and 90 percent of total lung cancer cases in different parts of the world. As in most types of malignancies, it is important that nonsmall cell lung cancer be detected early to ensure treatment success. However, given that symptoms often don't arise until much later, early detection is very difficult. Usually doctors judge their patients' likelihood of developing the disease with the help of thorough history taking or physical examination. If based on this lung cancer is suspected, a patient submits to sputum cytology or lung biopsy for confirmation.
Preliminary data from Japan have shown that the spiral CT scan may turn out to be an excellent tool for early detection of nonsmall cell lung cancer, Aapro says. "We don't have definitive evidence today but we are gathering evidence to show that with the use of spiral CT scan, we can detect very small nodules in the lung…very early in the stage when patients could be operated on for cure," he explains.
Aapro points out other problems because lung cancer exhibits symptoms similar as other diseases. For example, tuberculosis remains pervasive, and a doctor may sometimes consider the symptoms shown by the patient to be more of TB than cancer. This adds to treatment delay. "The time lag between the usual suspicion and the final diagnosis can be the time in which we go from a situation where we could operate for cure, with or without chemotherapy or radiotherapy, to a situation where it is very difficult to cure the patient," he explains.
Also, quite a number of patients will only seek medical help when the manifestations of the disease are no longer tolerable or are already causing much pain and discomfort.
Treatment
Over the years powerful chemotherapeutic agents have been developed to help improve cure rates. From the Vinca alkaloids to antimetabolites to platinum-based drugs to the taxanes, these drugs have proved effective in dealing with nonsmall cell lung cancer. "It is now a question of trying to define which agent is best for which type of situation," Aapro says.
Wide-scale studies have compared these agents in different associations, and it turns out that a "gold standard" in treatment is becoming "difficult to find." Explains Aapro: "[Experts] think today that we have to tailor the treatment to the patient. Some patients might profit from a treatment that imposes a little bit more on them for a few months to get the ultimate result. Other patients…might do as well in a treatment that is not that intensive. So we can't really speak of a gold standard."
One agent that has shown positive results in improving on survival rates and quality of life is taxane docetaxel (Taxotere). In a study involving 1,218 subjects from 28 countries, recently published by the European Journal of Cancer, patients with stage IV cancer or metastases to at least three other organs were randomized to receive vinorelbine plus cisplatin (standard regimen in first-line treatment of chemonaïve nonsmall cell lung cancer patients), docetaxel plus cisplatin, or docetaxel plus carboplatin. It turns out that median survival was higher in the docetaxel-cisplatin group (11.3 months) than in the vinorelbine-cisplatin group (10.1 months; p=0.044); the two-year survival rates are seven percentage points higher in the docetaxel-cisplatin group (21 percent) than in the vinorelbine-cisplatin group (14 percent). No statistically significant difference emerged between the vinorelbine-cisplatin and the docetaxel-carboplatin groups.
In terms of quality of life, those in either of the docetaxel combination groups showed better results than vinorelbine-cisplatin. In terms of pain, performance status, and weight change issues, the docetaxel groups showed favorable results. "Even if many feel that this treatment is intensive," Aapro comments, "if we look at it, the patients' quality of life is better because they do have less symptoms more quickly [in the docetaxel groups]."
Also, positive results have come up in the use of docetaxel among second-line, advanced nonsmall cell lung cancer patients. In addition, the use of docetaxel in the neoadjuvant management of the disease have yielded promising results.
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