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The Debate About Maintenance Is Not Over in Small-Cell Lung Cancer

Division of Medical Oncology, Selcuk University Meram Medical Faculty, Konya, Turkey

Hakan Bozcuk

Division of Medical Oncology, Akdeniz University Medical Faculty, Antalya, Turkey

To the Editor:

We read with interest the study of Arnold et al¹ about vandetanib as a maintenance therapy in patients with small-cell lung cancer (SCLC). They reported that maintenance therapy in SCLC with both chemotherapy and other agents did not affect the survival. However, a meta-analysis revealed the improvement of survival in SCLC with maintenance chemotherapy.² In this meta-analysis, maintenance chemotherapy improved 1- and 2-year overall survival by 9% (from 30% to 39%) and 4% (from 10% to 14%), respectively. Similarly, 1- and 2-year progression-free survival were also improved. Indeed, only a few randomized clinical trials reported so far (three of 14) have shown an overall survival difference in favor of maintenance chemotherapy. It is interesting that in two trials showing the superiority of maintenance chemotherapy, the induction therapy was cyclophosphamide, adriamycin, and vincristine, and the maintenance regimen was etoposide and cisplatin.^3,4 These two trials perhaps show that the inclusion of a less cross-resistant second-line chemotherapeutic regimen might improve the therapeutic efficacy of the whole strategy.

Another issue about the study by Arnold et al¹ is that although this was a randomized trial, the patients receiving vandetanib were less likely to have received chemotherapy (28% v 32%) and radiation (34% v 43%) after progression. Could this have affected overall survival? In our opinion, this should be regarded as a confounding factor that could have diminished the survival in the vandetanib arm.

In short, we believe the debate about the role of maintenance approaches in the management of SCLC is not over. Biologic agents and/or novel chemotherapeutic regimens should be tested in randomized trials in the maintenance setting.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

REFERENCES

1. Arnold AM, Seymour L, Smylie M, et al: Phase II study of vandetanib or placebo in small cell lung cancer patients after complete or partial response to induction chemotherapy with or without radiation therapy: National Cancer Institute of Canada Clinical Trials Group Study BR. 20. J Clin Oncol 25:4278-4284, 2007[Abstract/Free Full Text]

2. Bozcuk H, Artac M, Ozdogan M, et al: Does maintenance/consolidation chemotherapy have a role in the management of small cell lung cancer (SCLC)? A metaanalysis of the published randomized controlled trials. Cancer 104:2650-2657, 2005[Medline]

3. Einhorn LH, Crawford J, Birch R, et al: Cisplatin plus etoposide consolidation following cyclophosphamide, doxorubicin, and vincristine in limited small-cell lung cancer. J Clin Oncol 6:451-456, 1988[Abstract]

4. Johnson DH, Bass D, Einhorn LH, et al: Combination chemotherapy with or without thoracic radiotherapy in limited-stage small-cell lung cancer: A randomized trial of the Southeastern Cancer Study Group. J Clin Oncol 11:1223-1229, 1993[Abstract/Free Full Text]

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Related Reply

• In Reply:
  Lesley Seymour and on behalf of the BR.20 study team
  JCO 2007 25: 5840-5841 [Full Text]

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  JCO 2007 25: 4278-4284 [Abstract] [Full Text]

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