Second-line chemotherapeutic options

Docetaxel dosed at 75 mg/m2has been shown to offer clinically meaningful benefit to patients with advanced NSCLC who have failed platinum-containing chemotherapy.38, 39A randomised phase II trial comparing docetaxel dosed at 100mg/m2reduced to 75mg/m2 after a protocol amendment versus best supportive care in 103 patients showed a longer duration of survival for the chemotherapy arm (7 months 95% CI 5.5 9 months vs 4.6 months 95% CI 3.7 6 months; p=0.047). When compared separately, patients who were treated with docetaxel at 75mg/m2had significantly better survival than those treated with best supportive care (log-rank test; p = 0.01).39TAX 320 is a phase III randomised study of 373 patients comparing docetaxel dosed at 100mg/m2or 75mg/m2versus a control of vinorelbine or ifosfamide.38Patients treated with docetaxel dosed at 75mg/m2every 3 weeks had significantly greater 1-year survival than those with control treatment (32% vs. 19%; p = 0.025).

A subsequent randomised phase III trial comparing pemetrexed versus docetaxel as second line treatment in patients with advanced NSCLC showed equivalent efficacy outcomes by way of OS (8.3 months vs 7.9 months; HR 0.99 95% CI 0.82 1.2; p = 0.226), progression free survival and overall response rates (9.1% vs 8.8%).40The side effect profile of pemetrexed was favorable in comparison to docetaxel.40A secondary analysis further identified differing efficacy for pemetrexed over docetaxel in patients with non-squamous histology.41

Cost Effectiveness

Cost effectiveness of second-line chemotherapy has been assessed. Docetaxel was associated with significantly lower treatment period cost and was more favorable with regards to cost-utility ratio as compared to pemetrexed. When compared to best supportive care, the cost utility of docetaxel was USD $35,668 per QALY whilst the cost utility per QALY for pemetrexed was USD $44,770.42

Recommendations on Second Line Chemotherapeutic Options for Advanced NSCLC

1. The workgroup committee unanimously recommends consideration of clinical trials.

2. Docetaxel or pemetrexed (restricted to non squamous in histology) can be considered in fit patients as second line treatment of advanced lung cancer (Level I, B).