The guidelines on non–small cell lung cancer (NSCLC) were released on November 17, 2018, by the Spanish Society of Medical Oncology.
Adequate tissue material for histologic diagnosis and molecular testing should be obtained, to allow for individual treatment decisions.
The World Health Organization (WHO) classification for pathologic diagnosis is required, as well as International Association for the Study of Lung Cancer (IASLC) classification of adenocarcinoma.
For therapeutic implications, specific subtyping of NSCLC is strongly recommended.
Molecular testing in stage IV non–squamous cell carcinoma (SCC) NSCLC should include EGFR mutations, ALK rearrangments, and ROS-1 translocations by a validated technique.
In patients progressing on first- or second-generation EGFR tyrosine kinase inhibitor (TKI) therapy, determination of EGFR T790M in plasma or tissue should be performed.
Programmed death–ligand 1 (PD-L1) expression should be tested in all patients with advanced NSCLC at baseline.
Patients medically fit for surgery should undergo lobectomy or anatomic pulmonary resection plus systematic mediastinal lymph node dissection.
Medically inoperable patients with node-negative NSCLC and tumors ≤5 cm should receive stereotactic ablative radiotherapy (SART).
Adjuvant chemotherapy (four cycles of cisplatin-based chemotherapy) is recommended in stage II; it is not recommended in stage I unless the tumor is > 4 cm.
Postoperative radiotherapy (PORT) is not indicated in completely resected stage I–II disease.
Patients with completely resected disease should receive adjuvant chemotherapy (four cycles of cisplatin-based combination regimen) ± PORT.
Potentially resectable disease should be treated with resection followed by adjuvant chemotherapy, or by induction chemotherapy or chemoradiotherapy followed by surgery.
Unresectable stage III disease in medically fit patients should be treated with concurrent chemoradiotherapy (cisplatin-based combination), or with sequential chemoradiotherapy if concurrent treatment is not feasible; prophylactic cranial irradiation is not indicated. Treat with durvalumab if no progressive disease occurs after concurrent chemoradiotherapy.
Stage IV without driver mutations—first-line therapy
PD-L1 ≥ 50% - Pembrolizumab
PD-L1 < 50% or unknown – Platinum-based chemotherapy based on tumor histology
SCC - Platinum-based doublets (four to six cycles); immunotherapy (atezolizumab or pembrolizumab) and carboplatin plus paclitaxel or nab-paclitaxel)
Non-SCC - Platinum-based doublet: cisplatin/pemetrexed has more efficacy and less toxicity than cisplatin/gemcitabine; bevacizumab can be added to a platinum doublet if there are no contraindications. Pemetrexed is recommended for maintenance therapy. Alternatively, immunotherapy (atezolizumab or pembrolizumab) plus standard chemotherapy may be used.
Performance status (PS) 2 – Combination therapy, single-agent therapy, or best supportive care
PS 3-4 – Best supportive care
Stage IV without driver mutations—second-line therapy
PS 0–2, no prior immunotherapy - Pembrolizumab (if PD-L1 ≥1%), nivolumab, or atezolizumab
PS 0–2, prior immunotherapy - Platinum doublets
PS 0–2, contraindication for immunotherapy, or prior immunotherapy + chemotherapy - Docetaxel–nintedanib (non-SCC), docetaxel (SCC, non-SCC), pemetrexed (non-SCC)
PS 0–2, prior immunotherapy alone - Platinum doublets
PS 3–4 - Best supportive care
Stage IV with driver mutations
EGFR mutation – EGFR TKI: Erlotinib, gefitinib, afatinib, dacomitinib, osimertinib (also indicated for brain metastasis)
Progression on EGFR TKI: In T790 M–positive disease, osimertinib (if not previously given); in T790 M–negative disease, platinum-based chemotherapy
ALK mutation – First-line ALK TKI: alectinib, brigatinib, crizotinib or ceritinib
Progression on crizotinib: Ceritinib, alectinib, or brigatinib
Brain metastasis: Alectinib, brigatinib, or lorlatinib
ROS-1 mutation: Crizotinib
B-RAF V600 mutation: Dabrafenib plus trametinib
Oligometastatic disease: Local ablative strategies and TKI continuation if clinical benefit is still retained (if actionable mutation)
After curative-intent surgery: Medical history, physical examination, and spiral chest CT scan every 6–12 months for 2 years and annually thereafter
After SART: Medical history, physical examination, and spiral chest CT scan every 6 months for 3 years and annually thereafter; PET–CT ± biopsy if recurrence is suspected
Advanced disease: Early palliative care, with evaluation of response every 6–12 weeks
For more information, see Non-Small Cell Lung Cancer.
For more Clinical Practice Guidelines, please go to Guidelines.
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Non–Small Cell Lung Cancer Clinical Practice Guidelines (2018) - Medscape - Dec 06, 2018.