Chemotherapy for non-small-cell lung carcinoma: From a blanket approach to individual therapy

Only one third of patients with non-small-cell lung carcinoma (NSCLC) present with early-stage disease that is amenable to potentially curative resection and adjuvant therapy. Unfortunately, even in stage I NSCLC, 5-year survival rates are in the range of 55 to 72%. For unresectable disease in stages IIIB and IV, 5-year survival rates are < 5%. Postoperative chemotherapy (adjuvant chemotherapy) using cisplatin-based regimens has become the standard of care for resected stage II to IIIA NSCLC. However, adjuvant chemotherapy may be harmful in stage IA NSCLC, and its role for stage 1B is controversial. There are no conclusive data showing superiority of neoadjuvant chemotherapy (given prior to surgery) over adjuvant chemotherapy (given after surgery) or vice versa in early-stage NSCLC. Several emerging targeted therapy agents [e.g., inhibitors of vascular endothelial growth factor (VEGF), epidermal growth factor receptor (EGFR), or tyrosine kinase], and combination chemotherapy regimens are currently being evaluated in NSCLC. Specific patient subpopulation characteristics (including EGFR mutations) may be prognostically important to identify potential responders (or nonresponders) to therapy. This review will focus on chemotherapeutic approaches to treat both early stage (adjuvant and neoadjuvant chemotherapy) and metastatic disease including the use of maintenance therapy and novel agents.