Parameters for individualizing systemic therapy in non-small cell lung cancer

Rational drug design based on molecular targets is starting to revolutionize cancer care. To maximize its potential for patients, a concomitant leveraging of molecular knowledge for selection of patients to future and current therapeutic options is paramount. The terms "individualized", "personalized", or "precision therapy" are currently used to describe these efforts. Here, we summarize current knowledge for selection of systemic targeted and cytotoxic therapy for patients with non-small-cell lung cancer. Based on this knowledge, we present a potential decision algorithm to best select patients for currently available therapies, which include the treatment options single-agent erlotinib or gefitinib, the ALK inhibitor crizotinib, double agent gemcitabine and platinum, double agent platinum and pemetrexed, and as a default option a taxane combined with a non-platinum drug, for instance a vinca alkaloid. The addition of bevacizumab to double-agent chemotherapy is also discussed. Currently available data on predictive biomarkers are largely based on subgroup or companion biomarker analyses of patient cohorts or clinical trials. Current and emerging markers must be incorporated prospectively into the design of clinical trials that test novel and established agents to better understand their clinical utility and to refine selection parameters and marker interactions. Future development will lead to increasing complexity in clinical decision making with substantial anticipated benefits to patients including increased therapeutic efficacy, reduced toxicity, and better quality of life.

The role of betaIII tubulin in predicting chemoresistance in non-small cell lung cancer

Lung cancer is a leading cause of death among adults. Non-small cell lung cancer (NSCLC) accounts for approximately 85% of all lung cancer cases. For more than half of all patients diagnosis does not occur until the disease has metastasised. At this advanced stage, the 5-year survival rate is just 15%. Platinum-based chemotherapy forms the backbone of treatment for patients with advanced NSCLC and forms an important component of the therapeutic regimen for many patients with earlier stage disease. However, although a number of agents are available to partner the platinum-based compounds, treatment selection is largely empiric, and chemoresistance is a considerable barrier to improving outcomes. The identification of biologic and other markers to guide treatment selection, thus ensuring patients receive the most effective regimen for their individual tumour and avoid exposure to toxic agents from which they are unlikely to benefit, will be critical to improve outcomes for patients with NSCLC. The development of alternative agents for those patients who express predictors of a negative clinical response is of vital importance. A variety of biomarkers are emerging, including expression of DNA repair enzymes, ribonucleotide subunits and betaIII tubulin. Treatment algorithms based on elucidation of such markers to guide treatment selection can already be envisaged. For example, those patients with high betaIII tubulin expression should be considered for epothilone therapy as an alternative to taxane-based regimens. The epothilones may be preferred option as the evidence suggests that these agents retain activity versus taxane-resistant cancers. This paper reviews the evidence base for betaIII tubulin expression as a prognostic and predictive biomarker in NSCLC and briefly explores the implications for clinical decision making of this and other emerging biomarkers.

Definitive chemoradiotherapy for non-small cell lung cancer with N2 disease

The treatment of NSCLC continues to evolve over time. Newer therapies and techniques help achieve success in this difficult disease. Since the 1970s, one can observe trends in median survival and notice that they have improved from 9 to 10 months to now 15 to 24 months with concurrent chemoradiation. Unfortunately, despite the advances made, most patients still die from their disease. Chemoradiation without induction or consolidation therapy continues to remain the standard of care in this country for unresectable locally advanced NSCLC. Evaluation of epidermal growth factor receptor tyrosine kinase inhibitors and other biologics continue to be investigated but are not considered standard of care yet. Technologies continue to expand including the use of four-dimensional CT scans and PET scans to more accurately plan patients. Future application of molecular profiling to predict patients most likely to benefit from tailored chemotherapeutic approaches is awaited following validation in early- and advanced-stage disease. With continued diligence to testing new ideas in NSCLC, it is hoped that outcomes will continue to improve the lives of patients with this devastating disease.

From the podium to the patient: bringing the 2008 ASCO meeting to the clinic

Around 4,800 abstracts on preclinical and clinical research in different oncology areas were presented and discussed by oncology clinicians and scientists at the 44th American Society of Clinical Oncology meeting, the largest international forum in the field. As expected, the meeting provided valuable insights into future developments as well as enlightening clinicians regarding current controversies. This manuscript is an opinion-based review of the studies presented at the meeting, focusing on findings from randomized phase III trials and translational researches that, in the authors' opinion, are most likely to modify clinical practice or help scientists in designing future translational and clinical studies.