ASCO Updates Guidelines for Advanced Lung Cancer

The American Society of Clinical Oncology (ASCO) today released an update to its clinical practice guideline for stage IV non-small cell lung cancer. Published in the Journal of Clinical Oncology, the guidance provides recommendations for using systemic therapy—chemotherapy as well as targeted therapy—in first-, second-, and third-line regimens. Following a systematic review of published literature over a 7 year period between January 2007 and February 2014, a panel of experts from ASCO developed the following key recommendations:

First-line treatment

• If tumor lacks EGFR or ALK gene alterations, combination cytotoxic chemotherapy for patients with performance status 0-1 is recommended. For patients with performance status 2, chemotherapy or palliative care alone may be used.
• If tumor has sensitizing EGFR mutations, afatinib, erlotinib, or gefitinib is recommended.
• If tumor has ALK or ROS1 gene rearrangements, crizotinib is recommended.

Maintenance treatment (treatment after initial response to first-line treatment)

• Patients may be recommended to either switch to another regimen, or continue first-line therapy, or take a break from chemotherapy.

Second-line treatment

• Docetaxel, erlotinib, or gefinitib are options; pemetrexed is an additional option for patients with non-squamous cell carcinoma.
• Patients with EGFR mutations can receive chemotherapy or another EGFR inhibitor, depending on initial response.
• Patients with ALK rearrangements may be offered chemotherapy or ceritinib.

Third-line treatment

• Erlotinib may be offered for patients with performance status 0-3 who have not previously received erlotinib or gefitinib.

Emphasizing that age alone should not be a factor in the selection of treatment, the guideline recommends early palliative care, along with antitumor treatment.