I. Overview
1. The selection of drugs for patients with advanced initial therapy should be based on the principle of best efficacy and tolerable toxicity;
2. Tumor stage, weight loss, physical status (PS score) and gender are factors affecting survival prognosis;
3. platinum-based chemotherapy is more likely to prolong survival, improve symptoms and enhance quality of life (compared with best supportive care);
4. The histological type of non-small cell lung cancer (NSCLC) is important for the choice of regimen;
5. The efficacy of the new drug/platinum diphtherapy regimen has reached plateau: overall effective rate (ORR) ≈ 25-35%, time to disease progression (TTP) 4-6 months, median survival time 8-10 months, 1-year survival rate 30-40%, 2-year survival rate 10%-15%;
6. Regardless of age, those with poor physical status (PS 3 to 4) have difficulty benefiting from chemotherapy. If such patients are EGFR mutation positive, they can use EGFR-TKI drugs such as erlotinib or gefitinib.
Second, first-line treatment
1. Bevacizumab + chemotherapy or chemotherapy is suitable for patients with advanced or recurrent NSCLC with PS 0 to 1.
2. Cetuximab + vincristine/cisplatin is an option for patients with PS 0 to 1 (grade 2B).
3, Gefitinib, erlotinib, erlotinib and afatinib are recommended as first-line therapy for those with EGFR-sensitive mutations, and should not be used as first-line therapy for those without mutations or with unknown mutation status.
4. Crizotinib is indicated for patients with ALK gene rearrangements.
5. Cisplatin/pemetrexed (DDP/PEM) has the advantage of good efficacy and low toxicity in non-squamous cancers (compared with DDP/GEM), but in squamous cancers, the gemcitabine/cisplatin (DDP/GEM) regimen is again superior to DDP/PEM.
6. A two-drug combination regimen consisting of two drugs is preferred; a combination regimen of three cytotoxic drugs improves response rates but fails to prolong survival.
7, For PS 2 or elderly people, choose a single drug, or platinum-containing diphasic regimen.
8, Cisplatin or carboplatin has been shown to form an effective regimen in combination with any of the following drugs: paclitaxel, docetaxel, gemcitabine, etoposide, vincristine, vincristine, pemetrexed, or albumin-bound paclitaxel.
9. Combination chemotherapy regimens consisting of non-platinum next-generation drugs can replace platinum-containing two-drug regimens (e.g., gemcitabine/docetaxel, gemcitabine/vincristine).
Maintenance therapy
1. Maintenance: Patients whose disease is controlled after 4-6 cycles of chemotherapy should choose one or two drugs to continue treatment. Continued maintenance drugs are: bevacizumab, cetuximab, pemetrexed, bevacizumab + pemetrexed, gemcitabine
2. Drug switch maintenance: It means that after 4-6 cycles of chemotherapy and no disease progression, a drug that was not used in the first-line treatment started is selected for follow-up. Drugs used for maintenance switching are: pemetrexed (non-squamous cancer, first-line regimen without pemetrexed), erlotinib, docetaxel (squamous cancer)
3. No more treatment after the end of first-line treatment, only close monitoring is also a reasonable choice.
Second-line treatment
The currently recognized second-line drugs are: single-agent docetaxel, pemetrexed and erlotinib.
Docetaxel is superior to vincristine or isocyclophosphamide.
3. Pemetrexed is comparable to docetaxel in the treatment of adenocarcinoma and large cell carcinoma, but has lower toxicity.
4. Erlotinib is better than best supportive care.
5. Gefitinib, exatinib and afatinib are used for patients with EGFR-sensitive mutations.
V. Third-line therapy
If PS 0-2 and not used before, you can choose: docetaxel, pemetrexed (non-squamous cancer), erlotinib or gefitinib, or gemcitabine (all recommended for level 2B) .
VI. Management after disease progression
Except for patients with EGFR-sensitive mutations or ALK rearrangements using targeted drugs (erlotinib, gefitinib, afatinib, and crizotinib), if disease progression is clearly judged, do not maintain the original treatment, except in special cases.
VII. Drugs used for lung cancer treatment
Most drugs should be used in combination, some of which can be used alone (maintenance or second-line therapy).
Cisplatin
carboplatin
Paclitaxel
Docetaxel
Vincristine
Gemcitabine
Etoposide
Irinotecan
Vincristine
mitomycin