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Maintenance Therapy for Lung Cancer

What Is It and When Should It Be Used?

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Updated September 14, 2013

Written or reviewed by a board-certified physician. See About.com's Medical Review Board.

You may have heard of friends and loved ones who have been on maintenance therapy for cancer. Yet maintenance therapy for lung cancer has only been looked at fairly recently. When and why is maintenance therapy used for lung cancer?

What is Maintenance Therapy?

Before starting, it helps to define exactly what maintenance therapy is. It is a type of treatment that is used with advanced non-small cell lung cancer to attempt to improve survival, but not to “cure” cancer. This is in contrast to some treatments for the earlier stages of lung cancer that might be given with a cure in mind.

A simple definition of maintenance therapy is the continued active treatment of a tumor that hasn’t progressed (worsened) after initial chemotherapy –- until there are signs that the cancer has progressed (worsened.) In other words, it is a treatment given with the goal of keeping a tumor that is not actively growing fast in check, not a treatment designed to shrink a tumor.

When is it Used?

To define maintenance therapy for lung cancer further, it is the use of medications after someone has been treated with four cycles of "first-line" chemotherapy for advanced (stage 3B and stage 4) lung cancer, if their cancer did not progress during this first-line treatment. Whereas in the past, people were not treated further at this point (and instead this was followed by a period of “watchful waiting” –- that is, monitoring symptoms and radiology studies to see if the cancer would grow), maintenance therapy is designed to help with the symptoms of cancer, and, hopefully improve survival time beyond that provided by the first-line chemotherapy.

There are many controversies surrounding the use of maintenance therapy. As with any treatment, the side effects of treatment need to be weighed against any benefit. And -– in our current economy -– cost is also a consideration. Medications designed for “maintenance” can be very expensive. Some studies show only a very small improvement in survival (a matter of days to weeks at most), and families are often left with weighing a very modest improvement in survival with the financial burden of treatment.

What Medications Are Used?

At present, there are two medications that have been approved by the FDA for maintenance therapy for advanced lung cancer. Several other medications (and combinations of medications) are being studied in clinical trials. The approved drugs include:
  • Alimta (permetrexed) – In 2009, the FDA approved the use of Alimta for maintenance therapy for lung cancer.
  • Tarceva (erlotinib) – The FDA approved Tarceva for use as maintenance therapy for lung cancer in 2010.

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Who Benefits the Most?

As with most treatments for lung cancer, there are certain people who respond much better than others to therapy.

Studies with Alimta have shown that it seems to be effective for only two types of non-small cell lung cancer –- adenocarcinoma and large cell lung cancer. In contast, people with squamous cell lung cancer do not seem to respond as much. Alimta also appears to be more effective in people who have a particular mutation called an EGFR mutation in their cancer cells.

Studies with Tarceva also show improved survival (both progression free survival and overall survival) primarily for people with non-small cell lung cancers that are not squamous cell lung cancer. It also seems to benefit people with an EGFR mutation to a greater degree than those who do not have the mutation. The greatest survival benefit for maintenance therapy with Tarceva was found for never-smoking women who were in good overall health otherwise at the time of their treatment.

Sources:

Ahn, M. et al. The Effectiveness of Maintenance Pharmacotherapies for Non-Small Cell Lung Cancer. Clinical Medical Insights. Oncology. 2012. 6:253-262.

Banz, K. et al. Comparison of treatment costs of grade 3/4 adverse events associated with erlotinib or pemetrexed maintenance therapy for patients with advanced non-small-cell lung cancer (NSCLC) in Germany, France, Italy, and Spain. Lung Cancer. 2011 May 16. (Epub ahead of print).

Brugger, W. et al. Prospective Molecular Marker Analyses of EGFR and KRAS From a Randomized, Placebo-Controlled Study of Erlotinib Maintenance Therapy in Advanced Non-Small-Cell Lung Cancer. Journal of Clinical Oncology. 2011 Oct 3. (Epub ahead of print).

Cappuzzo, F. et al. Erlotinib as maintenance treatment in advanced non-small-cell lung cancer: a multicentre, randomized, placebo-controlled phase 3 study. Lancet Oncology. 2010. 11(6):521-9.

Ciuleanu, T. et al. Maintenance pemetrexed plus best supportive care versus placebo plus best supportive care for non-small-cell lung cancer: a randomized, double-blind, phase 3 study. Lancet. 2009. 374(9699):1432-40.

Cohen, M. et al. Approval summary: erlotinib maintenance therapy of advanced/metastatic non-small cell lung cancer (NSCLC). The Oncologist. 2010. 15(12):1344-51.

Cohen, M. et al. Approval summary: pemetrexed maintenance therapy of advanced/metastatic nonsquamous, non-small cell lung cancer (NSCLC). The Oncologist. 2010. 15(12):1352-8.

Coudert, B. et al. Survival benefit with erlotinib maintenance therapy in patients with advanced non-small-cell lung cancer (NSCLC) according to response to first-line chemotherapy. Annals of Oncology. 2011 May 24. (Epub ahead of print).

Dickson, R. et al. Erlotinib Monotherapy for the Maintenance Treatment of Non-Small Cell Lung Cancer after Previous Platinum-Containing Chemotherapy: A NICE Single Technology Appraisal. Pharmacoeconomics. 2011 Oct 3. (Epub ahead of print).

Greenhalgh, J. et al. Pemetrexed for the maintenance treatment of locally advanced or metastatic non-small cell lung cancer. Health Technology Assessment. 2010. 14(Suppl. 2):33-9.

Klein, R. et al. Cost-effectiveness of pemetrexed as first-line maintenance therapy for advanced nonsquamous non-small cell lung cancer. Journal of Thoracic Oncology. 2010. 5(8):1263-72.

Muir, V., and S. Chillon. Erlotinib: as maintenance monotherapy in non-small-cell lung cancer. BioDrugs. 2011. 25(3):139-46.

Petrelli, F. et al. Erlotinib as maintenance therapy in patients with advanced non-small cell lung cancer: a pooled analysis of three randomized trials. Anticancer Drugs. 2011. 22(10):1010-9.

Qi, W. et al. Erlotinib and pemetrexed as maintenance therapy for advanced non-small cell lung cancer: a systematic review and indirect comparison. Current Medical Research and Opinion. 2012 Mar 14. (Epub ahead of print).

Shepherd, F. Maintenance Therapy Comes of Age for Non-Small-Cell Lung Cancer, but at What Cost?. Journal of Clinical Oncology. 2011 Oct 3. (Epub ahead of print).

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