In a nutshell
The review summarizes recent clinical trials and provides up to date guidelines on the detection, treatment and follw-up of advanced non-small-cell lung cancer (NSCLC).
Some background
Lung cancer is the leading cause of cancer-related deaths globally with NSCLC as the most common subtype of lung cancer. The success of cancer therapy can vary depending on the cancer subtype. In NSCLC, there are three subtypes depending on the type of cancerous cells; adenocarcinoma, large cell carcinoma and squamous cell carcinoma. There are two common genetic mutations (changes) in NSCLC. These are mutations in the EGFR gene and ALK gene. Treatments are now available which can target cancer with these mutations specifically. Treatments are also prescribed based on a patient’s performance status (PS), which is a score of a patient’s general well being. The European Society for Medical Oncology (EMSO) has provided guidelines for diagnosing and treating metastatic (spread beyond the lung) NSCLC.
Methods & findings
The authors reviewed clinical trials to determine the most effective methods at diagnosing and treating NSCLC. The text below outlines a summary of their findings.
Tumor tissue should be tested to detect specific markers, such as the ALK or EGFR mutation. Screening for a mutation in the EGFR gene should be performed in advanced NSCLC except for those with squamous cell carcinoma. A treatment plan should be designed based on the results of this screening.
Once a patient has been diagnosed, they should provide a complete history. This includes smoking history, other illnesses, weight and physical examination. Other laboratory tests are then taking which evaluate the blood, kidney and bone function. A CT scan of the chest and upper abdomen would show the location of tumors. Some patients may need an MRI scan and bone imaging which shows tumors in the brain and bones. Following diagnosis and scans, a treatment plan should be made and discussed within a board of experts.
First-line treatment for patients with NSCLC without EGFR or ALK mutations should involve chemotherapy. The recommended chemotherapy uses a combination of two platinum-based drugs. These have been shown to reduce the risk of death by 22% compared to other chemotherapies. This should be followed by further therapy known as maintenance therapy which only uses one drug.
For patients with a high PS score (a higher score shows worse health), chemotherapy with best supportive care (treating the symptoms of the disease and side effects of the treatment) is recommended. For patients with the highest PS scores, best supportive care alone is recommended.
For elderly patients with a lower PS score and good organ function, chemotherapy with a combination of two platinum based drugs is recommended. If the patient is not eligible for two chemotherapy agents, single agent therapy is also an option.
If a patient progresses passed first line treatment, second line chemotherapy should be considered. Second line treatments have such as pemetrexed (Alimta) and docetaxel (Taxotere) have higher rates of toxic side effects. However if the side effects are manageable, treatment can be prolonged. For patients with advanced SCC that has progressed passed first-line treatment, nivolumab (Opdivo) is recommended. There is evidence to suggest immune checkpoint inhibitor drugs may be useful, as they activate the immune system to fight the cancer cells. For patients where chemotherapy is not suited, erlotinib (Tarceva) and afatinib (Gilotriff) are recommended. These are EGFR tyrosine kinase inhibitors, as they usually target cancer with EGFR mutations.
For patients with EGFR-mutation-positive cancer, the first-line treatment should be EGFR TKIs. There is a higher rate of relapse, however, with this type of cancer. Relapsed disease can become resistant to the first generation EGFR-TKIs. Patients should than receive newer EGFR-TKIs which can target some resistant cancers. If this is not feasible, chemotherapy should be offered.
For patients with ALK-mutation-positive cancer, the first line of treatment should be ALK-TKIs, which include crizotinib (Xalkori). For patients who progress after this treatment, newer second generation ALK-TKIs should be used.
Radiotherapy is sometimes useful in NSCLC to control pain symptoms of the disease. There are other procedures which also aid in helping relieve disease symptoms including surgery to remove abscesses and pleurodesis to prevent fluid build up in the lung.
For patients whose cancer has spread to the brain, tumor resection (removal) or radiotherapy is recommended. Older and less healthy patients might be ineligible for this and BSC is recommended. For patients whose cancer has spread to the bones, drugs containing a chemical called zoledronic acid can be used to ease side effects.
Patients should be evaluated after every 2-3 cycles of chemotherapy to detect potential relapse. They should than undergo follow-ups at least 6-12 weeks after treatment.
The bottom line
The authors summarized the up-to-date EMSO guidelines for the diagnosis and treatment of NSCLC.
Published By :
Annals of oncology
Date :
Sep 01, 2016
