title: Does an optimal therapeutic sequence exist in advanced non-small cell lung cancer?
abstract: BACKGROUND
  A growing percentage of patients affected by advanced non-small cell lung cancer who progressed after first-line chemotherapy still have a good performance status and require second-line treatment.
  
  
  OBJECTIVE
  An overview of the state of the art of second-line therapeutic options is presented.
  
  
  METHODS
  The scope of the review is to give an update on the therapeutic options currently available for the second-line treatment of patients with advanced non-small cell lung cancer.
  
  
  CONCLUSIONS
  Among chemotherapeutic drugs docetaxel and pemetrexed have been approved for second-line treatment of advanced non-small cell lung cancer. Although the drugs are equiactive in terms of response rate and survival parameters the latter has a clear-cut advantage in terms of tolerability and quality of life. Therefore, pemetrexed is considered the best second-line therapeutic option in order to avoid severe side effects. Among biologic agents the tyrosine kinase inhibitors gefinitib and erlotinib have been largely tested, but only the latter has been approved for second- and third-line treatment. Erlotinib has been reported to be particularly active in patients with adenocarcinoma, in females, in patients of Asian ethnicity and in epidermal growth factor receptor mutations and it is also active in the third-line setting. At present, no direct head to head comparison of erlotinib with any chemotherapeutic agent has been performed. A rational decision tree may therefore include pemetrexed or docetaxel (the former preferred for tolerability) or erlotinib as standard second-line therapy. Erlotinib has been also shown to be active as third-line treatment: however, in cases of patients with clinical characteristics suggesting a good response to tyrosine kinase inhibitors, erlotinib may be employed in an earlier phase.
authors.affiliation: Medical Oncology University of Palermo, Department of Experimental Oncology and Clinical Applications, Palermo, Italy. vittorio.gebbia@tin.it
authors.forename: Vittorio
authors.initials: V
authors.lastname: Gebbia
mesh_terms: D000970:Antineoplastic Agents / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D002289:Carcinoma, Non-Small-Cell Lung / Q000188:drug therapy*; D002986:Clinical Trials as Topic; D003663:Decision Trees; D006801:Humans; D008175:Lung Neoplasms / Q000188:drug therapy*; D011788:Quality of Life; D016879:Salvage Therapy; D016896:Treatment Outcome
chemical_list: D000970:Antineoplastic Agents