Optimal first-line and maintenance treatments for advanced-stage nonsquamous non-small cell lung cancer

During the past 10 years, the treatment of advanced-stage non-small cell lung cancer (NSCLC) has become increasingly complex, and debate continues regarding the optimal chemotherapeutic agents and duration of treatment. The addition of bevacizumab to platinum doublet chemotherapy, the use of pemetrexed for nonsquamous histology, and the introduction of maintenance chemotherapy are strategies that have been shown to improve overall survival beyond 12 months. Many acceptable treatment options are recommended in the NCCN Clinical Practice Guidelines in Oncology for NSCLC. This article discusses the first-line treatment of NSCLC with no identifiable mutations with FDA-approved targeted therapies for patients treated outside a clinical trial, particularly focusing on difficult clinical decisions, such as when the use of bevacizumab is appropriate, choosing a platinum partner, and treatment of patients with an ECOG performance status of 2. Data are summarized from several recent maintenance clinical trials, such as PARAMOUNT, AVAPERL, and PointBreak, and the implications these trials have on practical decisions oncologists must make when choosing an optimal treatment strategy for patients with advanced NSCLC are discussed.