We know that clinical guidelines are a “guideline” for physicians to follow. Recently, guidelines for lung cancer have been updated by authoritative professional bodies in China and the United States – the Chinese Society of Clinical Oncology (CSCO) and the National Comprehensive Cancer Network (NCCN). Comprehensive Cancer Network (NCCN). Overall, the two are relatively consistent, but there are some differences.
Some of these differences stem from our national situation, economic conditions, and policy and regulatory constraints, and some are due to different academic views of domestic and foreign experts. In addition, our guidelines incorporate some Chinese research data and domestically produced drugs, which are also more suitable for our patients. China’s research and exploration in the field of lung cancer has progressed by leaps and bounds in recent years, and the gap with foreign countries has narrowed significantly. Some experts and research have even led the international cutting-edge direction. However, there are still fewer new drugs in China than abroad.
For targeted therapy in non-small cell lung cancer (NSCLC), our guidelines generally make more aggressive recommendations.
1. Our guidelines recommend that patients with N1/N2 found after lung cancer surgery should be tested for EGFR gene mutations and can be considered for postoperative adjuvant targeted therapy. And the US guidelines do not make this recommendation.
EGFR, known as epidermal growth factor receptor, is one of the major targets of targeted therapy today, and these drugs are also known as EGFR-tyrosine kinase inhibitors (EGFR-TKI), such as gefitinib (trade names like Erythroxel) and erlotinib (trade names like Troche).
N1 is when the tumor invades the ipsilateral peribronchial lymph nodes, intrapulmonary lymph nodes, or hilar lymph nodes; N2 is when the tumor invades the ipsilateral mediastinal lymph nodes or lymph nodes under the tracheal bulge.
This recommendation is based primarily on the results of two studies – CTONG1104 (ADJUVANT) and the EVAN study. Both studies showed that for these patients, targeted drugs were better than chemotherapy after surgery.
2. Our guidelines recommend targeted therapy for patients with EGFR-sensitive mutation-positive NSCLC with no fewer than 3 brain metastases.
This is based on the results of the BRAIN study led by Professor Yilong Wu at the Guangdong Provincial People’s Hospital in China. This study showed that the use of exatinib, an EGFR-targeting agent, was more effective than whole brain radiotherapy (WBRT) in patients with EGFR mutation-positive brain metastases.
In addition to the two main points above, there are differences between our guidelines and those of the United States in the following areas.
3. Our guidelines have more specific recommendations for Next Generation Sequencing (NGS).
In recent years, several studies have used NGS to do multigene testing in patients, some of which are currently available as therapeutic targets, and potentially to identify currently unknown lung cancer-related genes. The specimen used for NGS can be tumor tissue, or free cancer cell DNA from peripheral blood.
But at present, NGS can be used to identify genes that are currently unknown.
However, there are still some problems with NGS, such as high price, unregulated market, lack of assurance of test efficiency and quality, lack of sufficient abundance of targeted drugs, and lack of countermeasures leading to detection of mutations, which limit the large-scale adoption of NGS.
4. Regarding EGFR gene mutation detection methods, our guidelines emphasize the use of standard methods, namely the amplification refractory mutation system (ARMS) and super ARMS methods, which are not mentioned in the US guidelines.
However, our guidelines only recommend 3 genes for routine testing, due to the limitations of the drugs currently available in the clinic: EGFR mutations, ALK fusion molecules, and ROS-1 fusion molecules; the US guidelines also recommend more BRAF and PD-L1 molecular testing.
5. Differences in targeted therapies between the US and China
As for new drugs for targeted therapy, our guideline introduces but does not recommend some drugs that are available abroad but not yet available in China, such as the ALK inhibitors erlotinib, ceritinib, and brigatinib, as well as the immunotherapy drug nivolumab (nivolumab, trade name Opdivo, recently launched in China, and (Chinese name nabulizumab), pembrolizumab (pembrolizumab, trade name Keytruda, Chinese name pablizumab), atezolizumab (atezolizumab, trade name Tecentriq), ipilimumab (trade name Yervoy), durvalumab (trade name Imfinzi), etc.
It is also pleasing to see that some drugs developed by domestic companies are included in our guidelines, such as the generation EGFR-targeting drug exatinib.
In addition, Apatinib and Anrotinib, which are mentioned in our guidelines, are also new targeted therapeutics developed in China.
In summary, our new guidelines make more aggressive recommendations for targeted lung cancer therapy overall, based on the results of several studies in our patients.
Medicine is a science that is always evolving, and the emergence of new research evidence can lead to guideline rewrites at any time. And doctors don’t copy guidelines when they see you, they take a variety of factors into account. Therefore, this article is not a substitute for your doctor’s opinion, and you should follow your doctor’s instructions regarding your specific condition.
For additional updates and comparisons between the US and Chinese guidelines, click on the related reading if you want to learn more: