Stage 4 Lung Cancer: How Long Can I Live? (2)

I saw a patient today with stage 4 lung cancer. He told me he has another 4-6 months to live, according to his doctor.

Is it true? No

Nowadays, it is not just ‘stage 4’ determining the survival time.

Let me elaborate. I will try to keep it simple.

Histology

First, there is the histology of the lung cancer: small cell lung cancer (SCLC – most aggressive lung cancer) or non small lung cancer (NSCLC; adenocarcinoma, squamous, etc.).

• For extensive stage SCLC, the median/ average survival time with chemotherapy is about 8.4 months. (Sundstrom, JCO, 2002)
• If the histology is NSCLC with no targetable mutation driver and unsuitable for immunotherapy, chemotherapy still offer median/ average survival time of 10.8 months – 11.8 months.

GV Scagliotti, JCO, 2005

Targetable Mutation Driver (EGFR, ALK, ROS1)

For advanced/ stage 4 non small cell lung cancer (NSCLC), specifically adenocarcinoma, those with EGFR and ALK mutations will have longer survival with EGFR and ALK tyrosine kinase inhibitors (TKIs) treatment.

Median/ average overall survival with EGFR-TKIs range between 21.6 months – 30.9 months

List of 1st and 2nd generation EGFR-TKIs

Median/ average overall survival with TKIs targeting ALK mutation ranges between 16.7 months – 20.3 months.

List of ALK-TKI trials

List of ALK-TKI trials

Immunotherapy

What more? Immunotherapy.

Results from immunotherapy trials had been very promising and there is possibility for long term remission.

In many trials, the median/ average survival duration data is not mature yet because many patients are still alive.

Immunotherapy therapy in first line NSCLC +/- chemotherapy had significant improvement in median overall survival.

In second line NSCLC treatment with immunotherapy also showed significant improvement in median overall survival.

Finally

For advanced lung cancer, a lot of different treatments had been introduced in recent time, which translate to longer overall survival.

Please do not tell patients that they have just 6 months to live anymore.

In fact, it is one of the cancer with the longest survival now.

Just advice them to seek treatment promptly.

UPDATE (8/6/2018)

JCO, Mok 2018

• ARCHER 1050, a randomized, open-label, phase III study
• Dacomitinib (irreversible pan-HER inhibitor) versus gefitinib in first line treatment
• Patients with advanced non–small-cell lung cancer (NSCLC) and EGFR mutation positive
• Improvement in progression free survival – 14.7 months with dacomitinib versus 9.2 months with gefitinib
• Average/ median overall survival was 34.1 months with dacomitinib versus 26.8 months with gefitinib
  • At 2.5 years, 56.2% and 46.3% with dacomitinib and gefitinib, respectively are still alive

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