What are the options for neoadjuvant and adjuvant chemotherapy regimens?

Neoadjuvant and Adjuvant Chemotherapy Options in Cancer Treatment

For patients with resectable stage III non-small cell lung cancer (NSCLC), systemic neoadjuvant therapy should be administered, with platinum-based regimens being the standard of care. 1

Neoadjuvant Chemotherapy Options

Non-Small Cell Lung Cancer (NSCLC)

• Platinum-based regimens are the standard for neoadjuvant therapy in NSCLC, with high-level evidence supporting their use 1
• For patients with N2 disease planned for surgical resection, either neoadjuvant chemotherapy or neoadjuvant concurrent chemoradiation is recommended 1
• Neoadjuvant chemotherapy has shown a 13% reduction in the relative risk of death compared to surgery alone in resectable stage IB-IIIA NSCLC 1
• Benefits of neoadjuvant approach include:
  • Higher compliance to systemic platinum-based treatment (90% vs 61% in adjuvant setting) 1
  • Reduction in tumor size with increased operability 1
  • Early eradication or prevention of micrometastasis 1
  • Opportunity to assess treatment efficacy 1

Superior Sulcus Tumors

• For patients with resectable superior sulcus disease, neoadjuvant concurrent chemoradiation is specifically recommended 1

Pancreatic Cancer

• For borderline resectable pancreatic cancer, acceptable neoadjuvant regimens include:
  • FOLFIRINOX 1
  • Gemcitabine/albumin-bound paclitaxel 1
  • Gemcitabine/cisplatin (especially for patients with BRCA1/2 or other DNA repair mutations) 1
• Neoadjuvant therapy should preferably be administered at or coordinated through a high-volume center 1

Bladder Cancer

• Standard neoadjuvant regimens for muscle-invasive bladder cancer include:
  • DDMVAC (dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin) with growth factor support for 3-4 cycles 1
  • Gemcitabine and cisplatin for 4 cycles 1
  • CMV (cisplatin, methotrexate, and vinblastine) for 3 cycles 1
• Neoadjuvant chemotherapy is preferred over adjuvant-based chemotherapy based on higher level of evidence 1

Adjuvant Chemotherapy Options

Non-Small Cell Lung Cancer

• Cisplatin-based doublet regimens are standard of care for adjuvant therapy in resected NSCLC 1
• Common regimens include:
  • Cisplatin-vinorelbine 1
  • Cisplatin-etoposide 1
  • Cisplatin-pemetrexed (for nonsquamous histology) 2, 3
• Pemetrexed-cisplatin has shown good safety profile with 81% of patients completing treatment without severe toxicity 3

Pancreatic Cancer

• For resected pancreatic cancer, adjuvant options include:
  • Gemcitabine monotherapy 1
  • Gemcitabine plus capecitabine (superior to gemcitabine alone) 1
  • 5-FU/leucovorin (similar efficacy to gemcitabine) 1

Bladder Cancer

• For patients with pathologic T3, T4, or N+ disease after cystectomy, adjuvant cisplatin-based chemotherapy shows survival benefit 1
• DDMVAC is preferred over standard MVAC based on better tolerability and efficacy 1

Comparing Neoadjuvant vs. Adjuvant Approaches

Benefits of Neoadjuvant Therapy

• Higher compliance to chemotherapy (90% vs 61% in adjuvant setting) 1
• Potential to downsize tumors and increase likelihood of margin-free resection 1
• Allows assessment of tumor response to guide further treatment 4
• Ability to treat micrometastases at an earlier stage 1

Benefits of Adjuvant Therapy

• Does not delay definitive surgical treatment 4
• Well-established survival benefit in multiple tumor types 1

Special Considerations

• For patients who received neoadjuvant treatment, data supporting additional therapy after surgery are limited 1
• The choice of adjuvant regimen after neoadjuvant therapy may be based on observed response to neoadjuvant therapy and patient factors 1
• Carboplatin should not be substituted for cisplatin in the perioperative setting for bladder cancer 1
• For patients with borderline renal function, split-dose administration of cisplatin may be considered (such as 35 mg/m² on days 1 and 2 or days 1 and 8) 1
• Patients with BRCA1/2 or other DNA repair mutations may benefit from specific regimens like gemcitabine/cisplatin 1

Practical Recommendations

• Neoadjuvant therapy should be considered for all patients with resectable stage III NSCLC 1
• For NSCLC with N2 disease, either neoadjuvant chemotherapy or chemoradiation is appropriate 1
• For borderline resectable pancreatic cancer, neoadjuvant therapy is recommended to improve resectability 1
• For muscle-invasive bladder cancer, cisplatin-based neoadjuvant chemotherapy is preferred over adjuvant therapy 1
• The decision between neoadjuvant and adjuvant approaches should consider tumor characteristics, resectability, and patient factors 4