Originally published as JCO Early Release 10.1200/JCO.2008.17.5844 on March 9 2009

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Meta-Analysis of Single-Agent Chemotherapy Compared With Combination Chemotherapy As Second-Line Treatment of Advanced Non–Small-Cell Lung Cancer

Massimo Di Maio, Paolo Chiodini, Vassilis Georgoulias, Dora Hatzidaki, Koji Takeda, Floris M. Wachters, Vittorio Gebbia, Egbert F. Smit, Alessandro Morabito, Ciro Gallo, Francesco Perrone, Cesare Gridelli

From the Clinical Trials Unit, National Cancer Institute; Department of Medicine and Public Health, Second University of Napoli; Division of Medical Oncology, "N.Giannettasio" Hospital, Rossano; La Maddalena, University of Palermo; Division of Medical Oncology, "S. Giuseppe Moscati" Hospital, Avellino, Italy; Department of Medical Oncology, University General Hospital, Heraklion, Crete, Greece; Osaka City General Hospital, Osaka, Japan; Department of Pulmonology, University Medical Center, Groningen; and Department of Pulmonary Diseases, Vrije Universiteit Medical Centre, Amsterdam, the Netherlands.

Corresponding author: Cesare Gridelli, MD, Division of Medical Oncology, "S.G. Moscati" Hospital, Contrada Amoretta, 83100 Avellino, Italy; e-mail: cgridelli{at}libero.it.

Purpose Doublet chemotherapy is more effective than single-agent as first-line treatment of advanced non–small-cell lung cancer (NSCLC). As second-line treatment, several randomized trials have been performed comparing single-agent with doublet chemotherapy, but each trial had an insufficient power to detect potentially relevant differences in survival.

Methods We performed meta-analysis of individual patient data from randomized trials, both published and unpublished, comparing single-agent with doublet chemotherapy as second-line treatment of advanced NSCLC. Primary end point was overall survival (OS). All statistical analyses were stratified by trial.

Results Eight eligible trials were identified. Data of two trials were not available, and data of six trials (847 patients) were collected. Median age was 61 years. Performance status was 0 or 1 in 90%; 80% of patients had received previous platin-based chemotherapy. OS was not significantly different between arms (P = .32). Median OS was 37.3 and 34.7 weeks in the doublet and single-agent arms, respectively. Hazard ratio (HR) was 0.92 (95% CI, 0.79 to 1.08). Response rate was 15.1% with doublet and 7.3% with single-agent (P = .0004). Median progression-free survival was 14 weeks for doublet and 11.7 weeks for single agent (P = .0009; HR, 0.79; 95% CI, 0.68 to 0.91). There was no significant heterogeneity among trials for the three efficacy outcomes. Patients treated with doublet chemotherapy had significantly more grade 3 to 4 hematologic (41% v 25%; P < .0001) and grade 3 to 4 nonhematologic toxicity (28% v 22%; P = .034).

Conclusion Doublet chemotherapy as second-line treatment of advanced NSCLC significantly increases response rate and progression-free survival, but is more toxic and does not improve overall survival compared to single-agent.

M.D.M. and P.C. contributed equally to this work.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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