Staying the Course
Patients are increasingly skipping treatment breaks and opting for ongoing treatment—known as maintenance therapy—to try to keep some types of cancer at bay.
Story by Melissa Weber and illustrations by Mikey Burton
About two and a half years ago, Brandon Hora, a young father of two, couldn't shake a cough. A trip to the doctor ended with an antibiotics prescription for what his physician thought was pneumonia, but a month went by without relief. That's when a CT scan revealed what was soon diagnosed as stage IV non–small cell lung cancer.
Doctors never shared Hora’s prognosis, but he says he knew from his own research that it wasn’t good. “I was in the mind frame of, ‘Let’s get going.’ I wanted to start fighting it now,” says Hora, 31, of New Carlisle, Ind.
Chemotherapy plus the targeted drug Avastin (bevacizumab) (see "What Are Targeted Drugs?") put the brakes on the cancer’s growth. Then, in an effort to lengthen that response, doctors kept Hora on Avastin long-term—a strategy called maintenance therapy. And it worked. For six months, the drug kept his aggressive cancer in check.
Typically, doctors give treatment for a limited time to stabilize a cancer and its symptoms or to put it into remission, and treatment resumes only if the cancer gets worse or comes back. Maintenance therapy, on the other hand, delivers one punch after another to fight off any cancer cells that might remain in the body after the initial therapy. It is being used or studied in numerous cancers, including lymphoma, multiple myeloma, and lung, colorectal and ovarian cancers.
For patients like Hora who have advanced cancer, maintenance therapy may help delay the progression of the disease. And ongoing treatment can have the added benefit of controlling certain disease-related symptoms, such as bone pain and shortness of breath.
“If you can’t eradicate the disease with your primary treatment, at least you’re doing something to exert pressure on that residual disease to try to control it,” says medical oncologist Andrew Zelenetz, the chief of the lymphoma service at Memorial Sloan-Kettering Cancer Center in New York City. In follicular lymphoma patients, for instance, initial therapy can leave some cancer remnants behind, Zelenetz says. “Even if you can’t find it on the scan, even if you can’t find it in the bone marrow biopsy, you know it’s there.”
Old Approach, New Drugs
Although the concept isn’t new, maintenance therapy is gaining momentum thanks to the availability of newer, less-toxic drugs. Depending on the type of cancer, the maintenance regimen may include one or more of the same drugs used in the initial, or first-line, therapy. Or it may introduce a different drug.
“You wake up some days and you’re extremely angry that you have to live with this disease every day. And then you get to a point where you don’t really care. If this is what it takes to keep him alive, then this is what we will do."
In the last couple of years, the U.S. Food and Drug Administration (FDA) has given the green light to the targeted drug Tarceva (erlotinib) and the more-traditional chemotherapy drug Alimta (pemetrexed) as maintenance treatments for advanced non–small cell lung cancer. Rituxan (rituximab), a targeted drug used to treat certain lymphomas and leukemias, is the latest to join the list of FDA-approved maintenance drugs, following its approval in January 2011 as a maintenance therapy for advanced follicular lymphoma.
Not every patient is a good candidate for maintenance treatment. Doctors typically do not recommend ongoing treatment for patients whose cancer isn’t aggressive, or for patients whose bodies cannot tolerate a barrage of drugs.
Instead, a break from therapy may be more appropriate, particularly for patients who respond well to treatment and who aren’t experiencing problematic symptoms related to their disease.
Chemotherapy can leave patients “a little beat-up,” says lung cancer specialist Mark Socinski, a medical oncologist and researcher at the University of Pittsburgh Cancer Institute. “I don’t think it’s wrong
to take a break to let side effects resolve,” he says.
But for patients who decide against a treatment holiday, maintenance therapy may offer peace of mind. The tradeoff: more trips to the doctor, higher costs for treatment, and the potential for side effects.
The maintenance Avastin didn’t cause any problems for Hora, whose only complaint is lingering nerve damage from his initial chemotherapy. Even so, for Hora’s wife, Tiffiany, ongoing treatment became a reminder of what they face. “You wake up some days and you’re extremely angry that you have to live with this disease every day. And then you get to a point where you don’t really care. If this is what it takes to keep him alive, then this is what we will do,” she says.
Keeping patients with metastatic lung cancer alive boils down to drug exposure, Socinski argues. Patients can’t benefit from available therapies if they don’t get them. Waiting until patients’ cancers progress means that up to half of them won’t get second-line therapy, because they get too sick to tolerate the medicine and its side effects. “Why don’t we give second-line therapy earlier, call it maintenance, and lo and behold, the survival is improved,” Socinski says. “In my mind, maintenance is a strategy to improve exposure and to improve the use of multiple lines of therapy. If you do that, you’re going to see more patients survive longer.”
But those improvements in survival are small, cautions medical oncologist Roy S. Herbst, the chief of medical oncology at Yale Cancer Center and Smilow Cancer Hospital at Yale-New Haven
in Connecticut. In the SATURN trial—the study that led to Tarceva’s approval in 2010 as a maintenance drug—patients who received Tarceva immediately after chemotherapy lived only one month longer than those who didn’t take Tarceva: a median of 12 months as opposed to 11 months. The drug, which caused some patients to develop a rash, worked best against the lung tumors that had a mutation in a specific gene, known as the epidermal growth factor receptor gene.