Maintenance Therapy for Lung Cancer

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Maintenance therapy is ongoing therapy for a disease that is administered after the acute phase of treatment has been completed. In the case of lung cancer, you would undergo first-line chemotherapy for a limited period of time, and then you might receive maintenance therapy to keep the cancer in check. The goal is to improve quality of life while offering a chance for longer survival.

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How Maintenance Therapy Works

Maintenance therapy is often part of the treatment strategy for advanced lung cancer that's not fully curable with surgery or radiation.

Maintenance therapy is used for disease management, not to cure disease. The goal is to achieve longer progression-free survival (the amount of time you can live without cancer growing). But it's important to know that maintenance therapy does more than palliative treatment, which focuses only on easing symptoms.

Supporting Chemotherapy Treatment

Maintenance therapy is increasingly used in managing non-small cell lung cancer (NSCLC). Stage 3A, stage 3B, or stage 4 NSCLC is treated with chemotherapy. A combination of drugs can often stop metastatic lung cancer from spreading.

Standard treatment for NSCLC includes several cycles of chemotherapy that may include platinum drugs, like carboplatin, combined with targeted therapy and/or immunotherapy. Beyond that, most patients would experience unacceptable levels of toxicity and side effects that would severely impact their health.

Once a course of chemotherapy is completed, cancer could begin growing again. To limit cancer growth after the standard course of chemotherapy, your doctor may recommend maintenance therapy. Some of the drugs that were used during initial treatment cycles may be continued, but certain drugs might not be used during maintenance therapy to avoid toxicity.

Maintenance therapy is focused on maintaining a state in which cancer is under control. You are likely to stay on this treatment unless you develop side effects or if there's evidence that the tumors are growing and spreading again.

Goals of Maintenance Therapy

There are several ways that maintenance therapy can help NSCLC patients:

  • Identify a more effective treatment: It's not always possible to predict which drugs will be most effective against your cancer. A new drug introduced during maintenance therapy may work better than something you've tried before.
  • Protect against chemotherapy resistance: Sometimes chemotherapy drugs that work well at first stop being effective, and cancer starts growing again. This happens when cancer develops resistance (mutates) after prolonged exposure. Switching the medications may help avoid this problem.
  • Optimize chemotherapy: When a new drug is incorporated, or part of a drug combination is stopped, it can improve effectiveness due to the way the drugs interact with each other.
  • Create antiangiogenic effects: Certain drugs can stop tumor blood vessels from forming, which prevents the tumors from growing.
  • Improve antitumor immunity: Some maintenance therapies help your own immune system destroy cancer cells.

Medications Used

Your doctors will consider several factors when choosing which type of medications to prescribe for maintenance therapy. The combination can include a non-platinum-based chemotherapy drug; an immunotherapy drug that boosts your immune system; and/or a targeted therapy drug.

When maintenance therapy includes a drug that was part of the initial treatment, it may be called continuation maintenance. When a different drug is introduced, it may be called switch maintenance.

Chemotherapy approved by the U.S. Food and Drug Administration (FDA) for maintenance therapy in treating NSCLC includes:

  • Alimta (pemetrexed)

This drug can improve survival when used after chemotherapy.

Immunotherapy drugs approved for maintenance therapy include:

  • Keytruda (pembrolizumab)
  • Tecentriq (atezolizumab)
  • Imfinzi (durvalumab)

Like other immunotherapy medications, Imfinzi helps your own immune system fight cancer. Unlike other maintenance therapies, it is also approved for use with the intent of curing lung cancer.

Targeted therapy drugs that have been approved for maintenance therapy include:

  • Avastin (bevacizumab)

As a man-made therapy that stops the growth of blood vessels, Avastin is an example of continuation maintenance.

Who Benefits Most From Maintenance Therapy?

As with most treatments for lung cancer, there are certain people who respond much better than others to therapy.

Studies of Alimta have shown that it seems to be more effective for people with lung adenocarcinoma. In fact, it seems to extend the survival rate significantly in patients with that type of NSCLC who use Alimta for maintenance therapy. 

Side Effects

There are risks of complications with maintenance therapy that can range from mild to severe.

Chemotherapy-Related

Those who are highly sensitive may still suffer some of the common side effects of chemotherapy while on Alimta alone.

These include:

Other serious side effects may include male infertility, low blood cell counts, kidney problems, skin irritation, and pneumonitis.

Targeted Therapy-Related

Avastin, like other targeted therapy drugs, offers the chance for good outcomes without the more inconvenient or serious side effects associated with chemotherapy. There are still some drawbacks to these drugs, though. The most common is skin rash.

Approximately 90% of patients on targeted therapy drugs that act on EGFR mutations develop an acne-like skin rash within two weeks of starting treatment. For the most part, though, the skin rash can be managed with over-the-counter creams or prescription treatments.

Immunotherapy-Related

Immunotherapy drugs boost the immune system to help you fight cancer, but once the immune system is revved up, it may also attack healthy tissue. This can affect the pulmonary, intestinal, and renal systems, among others.

That said, the most common side effects of the immunotherapy drug Imfinzi, for example, are:

  • Cough
  • Fatigue
  • Lung inflammation
  • Upper respiratory infections
  • Shortness of breath
  • Rash

Other Considerations

While maintenance therapy offers those with inoperable lung cancer some hope, the benefits need to be weighed against some negative factors.

  • Cost: Medications designed for maintenance can be very expensive. Your insurance may not cover the full cost.
  • Family burden: In addition to managing expenses, family members may need to bring you to appointments, oversee medication, help you with side effects from treatment, and take on responsibilities that may overwhelm them or be beyond their abilities.
  • Small increase in survival rate: The increase in survival is often a few weeks or months.
  • Treatment fatigue: Some people feel that continuous interventions prevent them from experiencing any sense of relief that treatment is over or feeling like they are "survivors."

A Word From Verywell

Maintenance treatments may allow you to manage your illness as you would a chronic disease, offering you a good chance to enjoy a longer, more fulfilling life. But you will need to have frequent check-ins with your doctor, and you should be ready for changes in your treatment plan if you develop signs that your current maintenance therapy is no longer working.

Before you begin maintenance therapy, be sure you are prepared to be flexible and to handle possible setbacks.

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  5. Barton-Burke M, Ciccolini K, Mekas M, Burke S. Dermatologic reactions to targeted therapy: A focus on epidermal growth factor receptor inhibitors and nursing careNurs Clin North Am. 2017;52(1):83-113. doi:10.1016/j.cnur.2016.11.005

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