Updated guidelines for the treatment of stage IV NSCLC

The American Society of Clinical Oncology (ASCO) gathered a panel of experts to update guidelines on systemic therapy (such as chemotherapy) for stage 4 non-small cell lung cancer (NSCLC). They provided updated guidelines with recommendations for first, second and third-line systemic therapy as well as targeted therapy. 

NSCLC can arise from different genetic mutations (changes). Common mutations include the epidermal growth factor receptor (EGFR), and the anaplastic lymphoma kinase (ALK) or ROS1 gene rearrangements. Based on these subtypes, NSCLC therapy can be targeted towards the particular mutation. These guidelines describe first, second and third-line treatment options for stage 4 NSCLC (cancer that has spread to other areas of the body).

The panel of experts reviewed 73 clinical trials from 2007 to 2014. The combined data was used to create an updated set of guidelines for the treatment of stage 4 NSCLC. The guidelines highlight first, second and third-line treatment recommendations. The guidelines take into account genetic mutations as well as performance status (PS) score. A higher PS score indicates the patient is experiencing more symptoms that affect daily life.

First-line therapy

The panel recommends that patients without mutations who have PS scores of 0 or 1 should be treated with combination chemotherapy. Bevacizumab (Avastin) is also recommended in patients who are receiving the chemotherapies carboplatin (Paraplat) and paclitaxel (Taxol). These can be coupled with palliative care, which focuses on providing relief from disease symptoms and both physical and mental stress.

For patients with higher PS scores, combination or single agent chemotherapy or palliative care alone is recommended.

In patients with EGFR mutations, adding the targeted therapies afatinib (Gilotrif), erlotinib (Tarceva), or gefitinib (Iressa) is recommended. In patients with the ALK mutation, crizotinib (Xalkori) is recommended. Crizotinib is also recommended for those with the ROS1 mutation, but the evidence is not as strong. 

Second-line therapy

The recommended second-line treatments include docetaxel (Taxotere), erlotinib, gefitinib and pemetrexed (Alimta). Patients with EGFR or ALK mutations who have progressed beyond first-line treatment should be treated with combination chemotherapy. Ceritinib (Zykadia) is also recommended for patients with an ALK mutation who progressed following treatment with crizotinib.

Third-line therapy

There is not enough data available to recommend third-line chemotherapy drugs. Erlotinib may be recommended in patients who were not treated already treated with this therapy. 

ASCO provided an update to current treatment guidelines for patients with stage 4 NSCLC.