An Update Committee of the American Society of Clinical Oncology NSCLC Expert Panel based recommendations on a systematic review of randomized controlled trials from January 2007 to February 2014.
RESULTS: This guideline update reflects changes in evidence since the previous guideline.
RECOMMENDATIONS: There is no cure for patients with stage IV NSCLC. For patients with performance status (PS) 0 to 1 (and appropriate patient cases with PS 2) and without an EGFR-sensitizing mutation or ALK gene rearrangement, combination cytotoxic
chemotherapy is recommended, guided by histology, with early concurrent
palliative care. Recommendations for patients in the first-line setting include
platinum-doublet
therapy for those with PS 0 to 1 (
bevacizumab may be added to
carboplatin plus
paclitaxel if no
contraindications); combination or single-agent
chemotherapy or
palliative care alone for those with PS 2;
afatinib,
erlotinib, or
gefitinib for those with sensitizing EGFR mutations;
crizotinib for those with ALK or ROS1 gene rearrangement; and following first-line recommendations or using
platinum plus
etoposide for those with large-cell neuroendocrine
carcinoma. Maintenance
therapy includes
pemetrexed continuation for patients with stable disease or response to first-line
pemetrexed-containing regimens, alternative
chemotherapy, or a
chemotherapy break. In the second-line setting, recommendations include
docetaxel,
erlotinib,
gefitinib, or
pemetrexed for patients with nonsquamous cell
carcinoma;
docetaxel,
erlotinib, or
gefitinib for those with
squamous cell carcinoma; and
chemotherapy or
ceritinib for those with ALK rearrangement who experience progression after
crizotinib. In the third-line setting, for patients who have not received
erlotinib or
gefitinib, treatment with
erlotinib is recommended. There are insufficient data to recommend routine third-line cytotoxic
therapy. Decisions regarding systemic
therapy should not be made based on age alone. Additional information can be found at http://www.asco.org/guidelines/nsclc and http://www.asco.org/guidelineswiki.