Lung Cancer Treatment - 2015 Update - Episode 9

Bevacizumab in Nonsquamous NSCLC


Mark A. Socinski, MD: It seems to me that bevacizumab in nonsquamous non-small cell lung cancer has had its ups and down. What are people’s practices now? Roy, how do you use bevacizumab in the first-line setting in the nonsquamous population?

Roy S. Herbst, MD, PhD: Well, I’ve changed a bit. I used to use it all the time and now I’m a little bit more discriminating. My sense is that using carboplatin/pemetrexed is probably almost as good, if not as good as using carboplatin/paclitaxel/bevacizumab. I guess the choice is whether I add bevacizumab to carboplatin/pemetrexed.

Mark A. Socinski, MD: A la POINTBREAK.

Roy S. Herbst, MD, PhD: A la POINTBREAK, which you know very well. And my sense is that in someone with a really good performance status, perhaps a bit younger, I’d do that. But in someone who’s a little on the margin, a little older, I’ve stopped doing that. Do you agree? Is that the right thing?

Mark A. Socinski, MD: Yes. What I was going to ask you is do you have a sense in SWOG 0819, a trial that allowed bevacizumab to be used if doctors thought it was indicated, what percentage of people actually got bevacizumab?

Roy S. Herbst, MD, PhD: That’s a very interesting aspect of 0819, because we said patients were either bevacizumab-appropriate or -inappropriate. And the inappropriate could be determined, because they had squamous disease or based on physician discretion—it’s about equally mixed. It’s embargoed data so I can’t discuss it now, but it’s going to be a very interesting aspect of the trial [in data released following the filming, approximately 41.5% of patients in the 1333-patient trial received bevacizumab].

Mark A. Socinski, MD: The other interesting aspect is that I don’t know how long this trial was open in SWOG but it seemed like it was a number of years, wasn’t it?

Roy S. Herbst, MD, PhD: Well, it was 0819, which means I got it through the NCI panels by 2008. It was actually conceived of about 2006, but it’s been open now for seven years.

Mark A. Socinski, MD: It will be interesting to look at bevacizumab, the first half of the trial versus the second half of the trial.

Roy S. Herbst, MD, PhD: This was a true Intergroup trial. There are probably as many patients from your group on it as from ours or from some of the others. We’re going to be able to mine these data for years.

Mark A. Socinski, MD: Mary Jo, what about Chicago, what’s the prevailing opinion about bevacizumab in Chicago, the home of the POINTBREAK regimen?

Mary Jo Fidler, MD: We participated in the phase II trial of the Patel regimen, carboplatin/pemetrexed/bevacizumab, and the phase II data looked outstanding with median survival of that group of 13.9 months, I believe. And we were early adopters of the triple combination until the POINTBREAK trial came out. I personally am using bevacizumab more with the paclitaxel backbone and I feel comfortable giving patients, even if they’re a little bit younger, platinum/pemetrexed and omitting the bevacizumab.

Mark A. Socinski, MD: This side of the panel, use of bevacizumab in first-line, obviously wild-type nonsquamous, non-small cell?

Naiyer Rizvi, MD: I still like giving pemetrexed/carboplatin/bevacizumab to patients or pemetrexed/cisplatin/bevacizumab and I continue pemetrexed/bevacizumab maintenance if they’re not going on a trial.

Roy S. Herbst, MD, PhD: So you use both drugs maintenance?

Naiyer Rizvi, MD: Yes.

Roy S. Herbst, MD, PhD: For how many cycles?

Naiyer Rizvi, MD: It’s open-ended.

Roy S. Herbst, MD, PhD: One thing always confused me; the bevacizumab I’m comfortable giving for longer periods of time.

Mark A. Socinski, MD: The pemetrexed can be tough.

Roy S. Herbst, MD, PhD: The pemetrexed — giving the two of them together for long periods of time can be tough, yes.

Naiyer Rizvi, MD: New Yorkers are tough.

Roy S. Herbst, MD, PhD: The doctors or the patients? Remember, we’re the doctors.

Mary Jo Fidler, MD: I agree. I feel that in the patients that had been on the combination for a long time, I was dropping off one of the two.

Transcript Edited for Clarity

Geoffrey R. Oxnard, MD: I tend to drop the bevacizumab before I drop the pemetrexed though, because I do think the data on pemetrexed maintenance is stronger than the data on bevacizumab maintenance, though that’s an ongoing study that needs to read out. I won’t give bevacizumab with cisplatin. I might give it with carboplatin, but more commonly I’ll give carboplatin and pemetrexed alone and in a more motivated, good performance status patient where I’m looking for a response, I’ll consider adding a third drug.