CT : Platinum + Pemetrexed

Induction with 4 cycles of Platinum based chemotherapy with Pemetrexed as a backbone followed by Pemetrexed continuation maintenance therapy had been the standard of care for many years.

Despite Cisplatin being the drug used in the PARAMOUNT trial, it usually comes with a challenging toxicity profile and a demanding administration. Therefore Carboplatin + Pemetrexed has been the most commonnly used combo for induction in daily practice and as the standard arm in clinical trials. The standard dosage is Carboplatin AUC 5 q 3 weeks + Pemetrexed 500mg/m2 x 4 cycles.

Cytopenias can be challenging for Carboplatin. I do not hesitate to use Carbo AUC 4 for patients at high risk of neutropenia and side effects (ECOG 1, low albumin, low lymphocyte count, frail…)

This regimen is mostly suitable when you have contraindication for IO.

Pemetrexed can be substituted with Gemcitabine or Paclitaxel in case of prohibitive renal function or after severe toxicity (like cutaneous which is despite being rare would be the most common to happen). In that case, some clinicians may continue induction up to 6 cycles of platinum doublets without maintenance.

Despite the results of multiple trials showing a PFS benefit (no OS) with the use of Bevacizumab as maintenance (ECOG 4599, AVAPERL, PointBreak… and later with IMpower150) Bevacizumab is not approved / funded in Canada in this setting.