Saving the best to the last: Can we wait for second-line?

Abstract

7013 Background: A common perception of some oncologists is that the vast majority of their patients with metastatic disease will receive 2nd line treatment upon progression. Therefore, “saving” good treatment options for the future may be acceptable. We aimed to examine whether this perception correlates with real-life. Methods: Using an oncology electronic database, consisting of >27,000 patients treated at our institution, we selected consecutive patients with metastatic or locally advanced lung, colon, pancreatic, bile duct and gastric cancers who started standard 1st line, consisting of at least doublet therapy. We then assessed the correlation between proceeding to 2nd line therapy and demographic and clinical variables, including age, gender, initial BMI, hemoglobin, WBC, creatinine, glucose, calcium, as well as survival. Results: A total of 553 patients met the inclusion criteria. Their median age was 66 and 317 were men. Their diagnoses were colon (197), lung (129), pancreas (101), bile duct (71) and gastric (55) cancers. Only 59% received at least one course of 2nd line treatment (61.9% colon, 65.1% lung, 66.3% pancreas, 35.2% bile duct and 54.5% gastric). Probability of reaching 2nd line treatment was associated with disease site (P=0.0002) as well as with age, with patients who received 2nd line being 2.5 years younger compared to those who did not (65 vs. 67.5 years, P=0.008). No other factor, including gender, BMI or standard laboratory values at presentation could predict chances of proceeding to 2nd line, for either the whole group or by primary cancer origin. Survival of patients not starting 2nd line was also significantly shorter across all tumor types. Conclusions: These real-life data indicate that only 60% of patients starting standard doublet or triplet treatment for advanced cancers will commence 2nd line therapy; and this cannot be reliably predicted in advance using standard clinical and laboratory characteristics. Our data challenge the practice of saving good treatment options for subsequent lines, and call for the development of tools enabling prediction of response and tolerance to treatment, pursuing for better patient selection and patient-tailored therapy.