Indeed, in JMEN trial (as well as in other ones) the discretion given to investigators in the choice of second-line therapy has been addressed as a major limitation, because it fails to provide any insight into the possibility that the benefit of maintenance therapy may be AZD6244 supplier obtained also by the appropriate use of the same agent as salvage therapy at the time of disease progression. In that respect, the design of the Fidias’ trial, with all patients receiving docetaxel as either maintenance or second-line treatment, appears to be a methodologically

more correct study design to test the efficacy of a strategy introducing a non cross-resistant agent before progression. In the SATURN trial only a minority of patients assigned to placebo actually received an EGFR-TKI: with the current evidence, we do not know if the improvement in OS observed with maintenance erlotinib would have been the same, or reduced, if the study protocol had imposed cross-over after disease progression. Importantly, the adoption of a pre-specified, built-in second-line treatment option offers the advantage A-769662 cost of reducing the proportion of patients who do not get access to further treatment, as demonstrated in the recently reported trial from Perol, in which more than 80% of patients in the RepSox observation arm received second-line pemetrexed [21, 30, 31]. Even if a bevacizumab maintenance in patients receiving bevacizumab combined

with chemotherapy in the context of their first-line regimen is considered common practice on the

basis of the registration trials, both of which maintained bevacizumab until progression after the completion of the assigned first-line regimen, with the notable exception of the recently-presented ovarian cancer trial clearly supporting the use of maintenance Rucaparib supplier bevacizumab, this specific issue has never been assessed in ad hoc designed randomized trials [4, 5, 38]. Currently there are at least two trials designed to clarify its role in maintenance: the ECOG three-arm, phase III study of Paclitaxel/Carboplatin/Bevacizumab followed by randomization to pemetrexed versus bevacizumab versus pemetrexed/bevacizumab in non-squamous carcinoma and a study with Pemetrexed/Cisplatin/Bevacizumab followed by Pemetrexed/Bevacizumab versus Bevacizumab alone [39]. The approximately 4-month median PFS with single-agent erlotinib maintenance in the SATURN trial and 4.76 months with the combination of erlotinib and bevacizumab in the ATLAS trial, highlights the importance of establishing the relative contribution of each agent when a combination therapy strategy is being evaluated in the maintenance setting [31, 32]. Another related question is whether subgroups of patients with specific clinico-pathological and/or molecular characteristics would especially benefit from the choice of a particular maintenance agent, among those currently available.