1. Q: What is the order of dosing for patients with EGRF mutated tumors? A: I am pretty sure that EGFR-TKI therapy should be given first, followed by second-line use of chemotherapy regimens. We lack relevant data because the overall survival of patients is similar regardless of the order of administration of the two classes of drugs. Some people prefer to start chemotherapy rather than TKI therapy because they are not sure if the patient is then fit to be given chemotherapy with cisplatin after TKI therapy is finished. I think there is no doubt that TKI therapy should be the first choice, given the data that are available on quality of survival, drug efficiency and progression-free survival benefit. 2. Q: What is the best option that can be done after disease progression? A: The best option is, of course, re-biopsy. In fact, a group of more than 100 patients who underwent re-biopsy was presented at the World Lung Cancer Congress in an attempt to better understand the mechanisms of tumor resistance. We have to re-biopsy patients whose tumors have progressed in order to understand what mechanisms are at play when tumors become resistant to drugs. This is going to be medical practice changing. It has to be done, even though it will be difficult. I would prefer that what is called liquid biopsy, which is circulating free DNA analysis, will give more hope for understanding the mechanisms of drug resistance. 3. Q: Regarding chemotherapy treatment, is it better to maintain or stop? A: Of course it should be maintained. We saw the PARAMOUNT trial comparing the effect of pemetrexed maintenance therapy with and without maintenance therapy after the end of cisplatin + pemetrexed treatment, and the results clearly supported maintenance therapy. Specific study: Pemetrexed maintenance improves overall survival in NSCLC patients If patients respond well to maintenance therapy, they can enjoy life better. People often question this, and they have difficulty believing that they can benefit from maintenance therapy. This is the most common question asked by patients with metastatic tumors. The data on adjuvant chemotherapy is particularly compelling and has been widely accepted. I would have to say that the overall benefit to patients is not great, but it is comparable to the benefit gained in adjuvant chemotherapy for breast and colon cancer. We can’t cure every patient, but we can improve 5, 6, and 7 year survival rates. 4.Q: How do you feel about quitting smoking? A: For patients diagnosed with metastatic non-small cell lung cancer (NSCLC), the life expectancy is 12 to 14 months. Whether they continue to smoke or not does not significantly change life expectancy. I would say it is almost unethical to ask these patients, who are under the pressure of oncology treatment, to quit smoking in the first place. This is because it is very difficult for these older smokers to quit. I would never advise them to quit smoking, instead I would easily say: listen, you have a year to go, so enjoy your life, smoke as much as you want, drink as much as you want, because it won’t change the final outcome. But for patients who have had their tumors removed and who have received radiotherapy and then progressed locally, the situation is completely different. It is possible for these patients to be cured. In both cases, it is very, very important to quit smoking. There is a definite association between tumor recurrence and continuous smoking. In these cases I would ask the patient to quit smoking. Continued exposure to tobacco is known to increase the risk of tumor recurrence. However, if the patient’s tumor is stage IV, then it is difficult to persuade the patient to quit smoking.