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This Week in NEJM: Mar 10, 2011

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In NEJM this week, clinicians discuss the case of a 64-year-old, non-smoking woman diagnosed with lung cancer. A year after her diagnosis, bone and liver metastases developed and she was treated with carboplatin, paclitaxel, and bevacizumab. Despite treatment, progressive bone metastases are noted after six weeks of therapy and an oncologist recommends the initiation of erlotinib therapy. "Erlotinib and gefitinib appear to be especially effective in tumors with gene mutations that activate EGFR," the authors write. "Such tumors may become dependent on the activity of the EGFR pathway for their survival." The National Comprehensive Cancer Network recognizes erlotinib as an option for treatment in patients with advanced NSCLC. In patients who carry an EGFR mutation, erlotinib monotherapy is suggested as a first-line therapy, the authors write. Although evidence supporting the value of EGFR mutational analysis is growing, there has been no study to date that shows benefit in overall survival from treatment based on mutational status, the clinicians add. In the case of the 64-year-old patient, erlotinib was recommended even without benefit of mutational status as erlotinib has been shown to be effective as second-line therapy in patients without the mutation.

Also in NEJM this week, researchers call into question the parameters of a recent trial that studied the use of adjuvant docetaxel in node-negative breast cancer. One researcher from India questioned whether the administration of granulocyte colony-stimulating factor to more than 50 percent of the patients in the study caused a "bias" in the trial, adding that it would be interesting to know how the group of patients fared who did not receive granulocyte colony-stimulating factor. Miguel Martin, the original study's first author, responds saying such an analysis would not be informative. The majority of the 230 patients who didn't receive granulocyte colony-stimulating factor had received it at some point in their therapy. "Because a large fraction of the patients received G-CSF, there is no suitable subgroup of patients who did not receive G-CSF for comparison," Martin adds.

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