Too old for this.

Top Line: Cancer treatment often involves pushing tumor toxicity to the limits of patient toxicity, so let’s reassess how this plays out for older patients with non-small cell lung cancer (NSCLC).
The Study: This pooled analysis of two similar phase 3 trials—that similarly failed to accrue—assessed the benefit of adding cisplatin to single agent chemo for patients 70 years or older with untreated advanced NSCLC. Importantly, both excluded patients with EGFR mutations and/or ECOG <1, and both had a primary endpoint of overall survival (OS). The MILES-3 trial (enrolled 299 of a planned 480) randomized patients to gemcitabine +/- cisplatin and MILES-4 (enrolled 232 of 550) randomized 2x2 to gem or pemetrexed +/- cisplatin. In the combined analysis, median OS was 8 months without versus 10 months with the addition of cisplatin, though there weren’t enough events for this to be significant. Median progression-free survival (PFS) was 3 months with versus 5 months without cisplatin, which did have enough events to be significant. The authors conclude a cisplatin doublet should no longer be offered to patients over 70, but tbh this is far from a slam dunk. Especially considering NCCN guidelines recommend cisplatin in combo with pemetrexed for non-squams (and in combo with gem for squams), and here 70% of enrollees had non-squams while only 22% received pemetrexed. Not to mention if KEYNOTE-042 is ever actually published, this may all become a moot point.
Bottom Line: A standard combo platinum doublet probably improves survival even in older patients with NSCLC without any targetable mutations, but only if they are fit enough to successfully complete it without hiccup before moving on to single agent pembro. | Gridelli, J Clin Oncol 2018


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