The necessity of adding chemotherapy to postoperative adjuvant treatment and in Stage IV non-small cell lung cancer (NSCLC) remains a topic of debate. In this article, Dr. Mark G. Kris from Memorial Sloan Kettering Cancer Center analyzes the value of chemotherapy in the adjuvant treatment of early-stage NSCLC with EGFR and ALK mutations, as well as in the treatment of advanced lung cancer.

When it comes to the necessity of chemotherapy, the clearest affirmative answer lies in the context of adjuvant treatment. It is essential to remember that following curative surgery, the goal is to cure the patient, and systemic therapy is used again to increase the chance of cure.

Chemotherapy in Adjuvant Treatment for EGFR-Mutated NSCLC: The first therapy proven to increase the chance of cure is chemotherapy. Recently, my clinical practice group conducted a survey, and all members (20 people) indicated that, in addition to using osimertinib, they would also administer chemotherapy to patients with completely resected EGFR-mutated NSCLC. While not all patients in clinical trials received chemotherapy, our group believes that every patient with EGFR-mutated NSCLC should receive adjuvant osimertinib plus chemotherapy.

Chemotherapy in ALK-Rearranged NSCLC: New data from the ALK adjuvant targeted therapy study (ALINA trial) has been released. Although the ALINA clinical trial randomized patients to receive alectinib or chemotherapy, and not all patients received chemotherapy, in clinical practice, doctors may also consider adding chemotherapy. Given the balance between benefits and risks, when aiming for curative treatment, patients are generally more willing to take on risks if the treatment could lead to a cure, provided that the doctor discusses this with the patient. Furthermore, I believe that doctors strongly recommend chemotherapy in such cases, even if the clinical trial did not include it. In my clinical practice group, at least 18 out of 20 members stated they would recommend chemotherapy.

Chemotherapy in Stage IV Lung Cancer Treatment: There has been much discussion recently about using chemotherapy combined with osimertinib as an initial treatment. In my practice group, only about one-quarter of doctors recommend starting treatment with chemotherapy plus osimertinib. One perspective is that the benefit of adding chemotherapy to osimertinib, which extends progression-free survival (PFS) by 10 months, may not be substantial enough to recommend chemotherapy to every patient. I respect this viewpoint. Besides cure, maintaining a disease-free state is the most important goal. By wisely administering chemotherapy, we can balance the benefits and risks appropriately. Doctors need to discuss the benefits and risks of chemotherapy with patients and carefully assess the risks. Any toxicity that could impair the patient’s quality of life must be improved or considered before continuing treatment. Finally, clinicians must be ready to adjust the treatment plan, closely monitor the patient, and engage in repeated discussions.is situation, we need to go all out and use any available therapy that can enhance the likelihood of cure.

Chemotherapy in Adjuvant Treatment for EGFR-Mutated NSCLC: The first therapy proven to increase the chance of cure is chemotherapy. Recently, my clinical practice group conducted a survey, and all members (20 people) indicated that, in addition to using osimertinib, they would also administer chemotherapy to patients with completely resected EGFR-mutated NSCLC. While not all patients in clinical trials received chemotherapy, our group believes that every patient with EGFR-mutated NSCLC should receive adjuvant osimertinib plus chemotherapy.

Chemotherapy in ALK-Rearranged NSCLC: New data from the ALK adjuvant targeted therapy study (ALINA trial) has been released. Although the ALINA clinical trial randomized patients to receive alectinib or chemotherapy, and not all patients received chemotherapy, in clinical practice, doctors may also consider adding chemotherapy. Given the balance between benefits and risks, when aiming for curative treatment, patients are generally more willing to take on risks if the treatment could lead to a cure, provided that the doctor discusses this with the patient. Furthermore, I believe that doctors strongly recommend chemotherapy in such cases, even if the clinical trial did not include it. In my clinical practice group, at least 18 out of 20 members stated they would recommend chemotherapy.

Chemotherapy in Stage IV Lung Cancer Treatment: There has been much discussion recently about using chemotherapy combined with osimertinib as an initial treatment. In my practice group, only about one-quarter of doctors recommend starting treatment with chemotherapy plus osimertinib. One perspective is that the benefit of adding chemotherapy to osimertinib, which extends progression-free survival (PFS) by 10 months, may not be substantial enough to recommend chemotherapy to every patient. I respect this viewpoint. Besides cure, maintaining a disease-free state is the most important goal. By wisely administering chemotherapy, we can balance the benefits and risks appropriately. Doctors need to discuss the benefits and risks of chemotherapy with patients and carefully assess the risks. Any toxicity that could impair the patient’s quality of life must be improved or considered before continuing treatment. Finally, clinicians must be ready to adjust the treatment plan, closely monitor the patient, and engage in repeated discussions.

To reiterate, when it comes to curative treatment, both patients and doctors are more willing to accept adverse events to increase the chances of cure. However, in the treatment of advanced cancer, where cure is not the goal, the willingness to accept adverse events is much lower. Even in such cases, clinicians need to have clear discussions with patients, weigh the pros and cons, and continually reassess during treatment; the answer is not one-size-fits-all.

Chemotherapy should not be discarded due to concerns about the therapy itself. The primary consideration should be whether chemotherapy is appropriate for the individual patient.

Mark G. Kris, MD

Memorial Sloan Kettering Cancer Center, New York