Solid Tumor Oncology, Cleveland Clinic Taussig Cancer Institute, 9500 Euclid Ave, R35, Cleveland, OH 44195, USA.
Curr Treat Options Oncol. 2012 Dec;13(4):478-90. doi: 10.1007/s11864-012-0209-1.
The standard of care for the treatment of patients with advanced NSCLC includes 4-6 cycles of platinum-doublet chemotherapy with or without bevacizumab, with modest improvements in survival. To improve upon outcomes, recent studies have investigated the role of maintenance therapy after first-line chemotherapy. This concept can be divided into continuation and switch maintenance. The majority of studies have shown significant improvements in progression-free survival (PFS) with the addition of maintenance, but the improved PFS has not always resulted in an improvement of overall survival (OS). Two notable exceptions are erlotinib and, for non-squamous NSCLC, pemetrexed. For patients with non-squamous NSCLC who respond or remain stable after four cycles of platinum-doublet chemotherapy, either continuation of pemetrexed (if included in the induction regimen) or switch to pemetrexed as maintenance has been shown to improve OS compared with observation. Whether maintenance pemetrexed improves OS compared with treatment with pemetrexed at progression is unknown. Recent trials suggest that maintenance therapy benefits both patients with initial response and stable disease after chemotherapy. There is insufficient evidence to support recommending the combination of pemetrexed and bevacizumab over maintenance pemetrexed alone as a switch maintenance approach, although the combination seems to be more effective than bevacizumab alone. The ongoing ECOG 5508 trial is examining this question. For both squamous and non-squamous NSCLC, switch maintenance with erlotinib has been shown to improve both PFS and OS, although the improvement is modest. Switch maintenance with docetaxel or continuation maintenance with gemcitabine confers improvements in PFS regardless of histology but has failed to show improvements in OS. For this reason, switch maintenance with erlotinib can be considered in patients with squamous NSCLC. Overall, maintenance therapy may benefit patients with good performance status who complete four cycles of induction chemotherapy with manageable toxicity, but there is insufficient evidence to make this a blanket recommendation for everyone. Maintenance should remain an individual decision between patients and the treating oncologist.
对于晚期 NSCLC 患者的治疗标准包括铂类双药化疗 4-6 个周期，联合或不联合贝伐珠单抗治疗，可适度提高生存率。为了改善治疗效果，最近的研究探讨了一线化疗后维持治疗的作用。这种治疗理念可分为延续性维持和转换性维持。大多数研究表明，维持治疗可显著提高无进展生存期（PFS），但改善的 PFS 并不总是导致总生存期（OS）的改善。有两个显著的例外，分别是厄洛替尼和非鳞状 NSCLC 中的培美曲塞。对于完成 4 个周期铂类双药化疗后有缓解或稳定的非鳞状 NSCLC 患者，如果诱导方案中包含培美曲塞，继续使用培美曲塞或转换为培美曲塞作为维持治疗均可提高 OS；而培美曲塞维持治疗是否优于疾病进展时的培美曲塞治疗，目前尚不清楚。最近的试验表明，维持治疗对初始缓解和化疗后疾病稳定的患者均有益。虽然联合方案似乎比单独使用贝伐珠单抗更有效，但没有足够的证据支持推荐培美曲塞联合贝伐珠单抗作为转换性维持方案优于单纯培美曲塞维持。正在进行的 ECOG 5508 试验正在研究这个问题。对于鳞状和非鳞状 NSCLC，厄洛替尼转换性维持治疗可改善 PFS 和 OS，尽管改善幅度不大。对于鳞状和非鳞状 NSCLC，无论组织学类型如何，厄洛替尼转换性维持治疗或吉西他滨延续性维持治疗均可改善 PFS，但未能改善 OS。因此，可考虑在鳞状 NSCLC 患者中使用厄洛替尼转换性维持治疗。总的来说，对于完成 4 个周期诱导化疗且毒性可耐受、体能状态良好的患者，维持治疗可能有益，但目前尚缺乏证据支持将其作为所有人的普遍推荐。维持治疗应作为患者和治疗肿瘤医生之间的个体化决策。
