晚期非小细胞肺癌一线化疗后的治疗策略

晚期非小细胞肺癌一线化疗后的治疗策略,安徽医科大学第一附属医院肿瘤内科陈振东,什么叫晚期肺癌？一线化疗后可能有几种情况？一线化疗后的治疗有哪些选择？ASCO：the treatment of stage4 NCSLC,什么叫晚期肺癌？,不可手术的期期,一线化疗后可能有几种情况？,进展稳定、稍有缩小或难以精确测量部分或完全缓解发现了新病灶，但不能肯定为进展目标病灶与非目标病灶的反应不同化疗有效但因为医疗或非医疗的原因改变治疗,一线化疗后的治疗：不同的情况,维持治疗是指在完成标准的几个周期化疗且疾病得到控制后再接受的化疗。理论基础：Goldie and Coldman假设，早期使用非交叉耐药的药物可以在耐药性产生前增加杀伤肿瘤细胞的效能。使治疗效果最优化，杀死更多的肿瘤细胞。完全缓解、部分缓解或者疾病稳定的患者最有可能从维持治疗中获益。但同时也延长了治疗时间，且化疗的毒性反应可在体内蓄积，导致过度治疗。一线化疗失败后的治疗严格意义上属于挽救治疗，但两者并没有本质区别。,一线化疗后的治疗有哪些选择？,放疗中医药治疗及最佳支持治疗化疗分子靶向治疗联合治疗,放疗,有下列情况者一般不做根治性放疗：两肺或全身广泛转移胸膜广泛转移有癌性胸腔积液癌性空洞或肿瘤巨大严重肺气肿心包或心肌有癌瘤侵犯者伴有感染，抗炎治疗不能控制肝、肾功能严重受损，KPS60分者。姑息放疗可能有价值（心理支持、老年人）,药物维持治疗,二线细胞毒药物，并非都是单抗类靶向治疗药物表皮生长因子受体酪氨酸蛋白激酶抑制剂联合治疗,Pemetrexed,July 6, 2009 FDA has approved pemetrexed for the maintenance therapy of advanced or metastatic NSCLC. Pemetrexed is the first drug indicated as a maintenance therapy in this setting.,J M E N 研究，patients received either pemetrexed (n= 441) or placebo (n= 222), along with the best supportive care. Patients had advanced or metastatic (stage3B or 4) NSCLC (both squamous and nonsquamous subtypes) that had not progressed after 4 cycles of initial platinum-based chemotherapy.,For all patients in the study, the pemetrexed treatment group had an overall survival of 13.4 months, compared with 10.6 months for the placebo group. For the nonsquamous subgroup, overall survival was 15.5 months for patients taking pemetrexed and 10.3 months for patients taking placebo (P= .002).,the trial was not designed to indicate whether maintenance therapy was superior to using pemetrexed at time of disease progression. dont think we have the answer as to when it is best to start pemetrexed. Should we start immediately after standard chemotherapy or later on?,多西紫杉醇,第一个被认可的二线治疗药物。Fidias等，进展期NSCLC，4周期卡铂联合吉西他滨的诱导化疗后，对治疗有反应或者稳定的患者随机分成2组，一组立即接受多西他赛，另外一组于疾病进展时接受多西他赛作为挽救治疗(延迟组)。结果：立即组的总有效率高于延迟组(425 VS 99 )；中位生存时间，立即组为119个月，延迟组91个月，但无统计学意义；中位PFS，立即组为65个月显著高于延迟组28个月(P 90%) approved by the FDA) in the past 4 years cost more than $20,000 for a 12-week course of therapy, 1.2-month survival benefit with cetuximab plus a platinum-based chemotherapy compared with chemotherapy alone was hailed as the new standard for NSCLC. cetuximab for NSCLC, which costs $80,000 for an 18-week course.,Drug Estimated Cost for Therapy,bevacizumab for metastatic breast cancer provides progression-free survival improvement but no increase in overall survival; estimated total cost of therapy, $90,816.,Drug Estimated Cost for Therapy,In the UK, the National Institute for Clinical Excellence (NICE) has established a maximum threshold of 30,000 per quality-adjusted life-year (QALY). cetuximab was not recently recommended for use by NICE for the treatment of recurrent and/or metastatic head and neck cancer. Drs. Fojo and Grady propose that an American threshold for anticancer drugs be set at $129,000, which is the cost of a QALY in patients treated with renal dialysis. J Natl Cancer Inst. Published online June 29，2009,注意研究结果,维持药物可以是诱导治疗时的药物，也可以是另外一种相对低