2009 : l'année de la maintenance en première ligne ?

Usual strategy consisting in stopping first-line chemotherapy and introducing second-line treatment at disease progression is due to toxicity of platin-based chemotherapy which does not allow giving it beyond 4-6 courses. The concept of maintenance is based on the continuation of a treatment until progression, for patients whose disease is controlled after a first-line chemotherapy. The sequential use of pemetrexed as maintenance therapy after platin-based chemotherapy in the JMEN study has so underlined an advantage in term of progression free survival and overall survival, with a confirmation of differential effect of pemetrexed according to histological types. Maintenance by erlotinib has been the subject of two trials (SATURN trial, and in association with bévacizumab in ATLAS trial). The results have shown a reduction of progression risk of 30% compared with placebo, with a significant survival advantage in SATURN, and without any negative impact on quality of life. All clinical categories of patients benefit from this treatment. The survival benefit of maintenance strategy seems to be related to the greater proportion of patients exposed to multiple lines of treatment. Some questions keep however unanswered: how to select patients who will benefit from maintenance strategy and which choice for maintenance treatment between cytotoxic chemotherapy and targeted therapy? This choice is mainly based on the toxicity profile and its impact on quality of life, the attended benefices being currently similar between a cytotoxic drug and a EGFR tyrosine kinase inhibitor.