The National Cancer Network (NCCN) released the first edition of the 2015 guidelines for the treatment of non-small cell lung cancer on Oct. 21, 2014. Medical Pulse has compiled the section on the systemic treatment of advanced advanced or metastatic non-small cell lung cancer, which is compiled below, in the hope that it will be helpful to readers.
Advanced non-small cell lung cancer
● The drug regimen that is acceptable to both physician and patient, most likely to benefit the patient, and least toxic should be used as the first treatment option for advanced lung cancer.
● Staging, weight loss, physical status, and gender can predict survival.
● Platinum-based chemotherapy may prolong survival, improve symptom control, and achieve a better quality of life than the best supportive therapy.
● The histology of NSCLC is important for the choice of systemic therapy.
● New drug/platinum combinations can produce stable overall remission rates (approximately 25%-35%), time to progression (4-6 months), median survival (8-10 months), 1-year survival (30%-40%), and 2-year survival (10%-15%) in appropriate patients.
● Unsuitable patients of any age (physical status 3-4) do not benefit from cytotoxic drug therapy, except for EGFR mutation-positive patients who are effective with erlotinib.
First-line therapy
● Bevacizumab + chemotherapy or chemotherapy alone is indicated for patients with advanced or recurrent NSCLC with stamina status 0-1. Bevacizumab should be continued until disease progression.
● Erlotinib is recommended as first-line therapy for patients with EGFR-sensitive mutations. In contrast, patients with EGFR mutation-negative or unknown EGFR status should not use erlotinib as first-line therapy.
● Afatinib is indicated for patients with EGFR-sensitive mutations.
● Crizotinib is indicated for patients with ALK rearrangement.
● In patients with non-squamous lung cancer, cisplatin/penemetrexed has better efficacy and lower toxicity than cisplatin/gicitabine.
● Cisplatin/gicitabine has better efficacy compared to cisplatin/pemetrexed in patients with squamous carcinoma.
● A two-drug combination regimen is recommended, and the addition of a third cytotoxic agent increases remission rates but does not improve overall survival. Monotherapy may be appropriate for specific patients.
● Studies have confirmed the effectiveness of cisplatin or carboplatin in combination with any of the following: paclitaxel, docetaxel, gemcitabine, etoposide, vincristine, vinorelbine, pemetrexed, or albumin-bound paclitaxel.
● New drug/non-cisplatin combination regimens (e.g., gemcitabine/docetaxel, gemcitabine/vinorelbine) may also be a possible option if there are available data demonstrating activity and tolerable toxicity.
Maintenance therapy
Sustained maintenance is defined as the use of at least one first-line therapeutic agent for more than 4-6 cycles without disease progression. Conversion maintenance is defined as initiation of a different drug not included in the first-line regimen with no disease progression after 4-6 weeks of initial therapy.
Sustained maintenance: Bevacizumab combination chemotherapy should be stretched until evidence of disease progression or unacceptable toxicity occurs and each clinical trial is designed to support their use.
● Continue bevacizumab after 4-6 weeks of platinum-doublet chemotherapy in combination with bevacizumab.
● For patients other than squamous cell carcinoma, use of 4-6 weeks of cisplatin in combination with pemetrexed chemotherapy followed by continuation of pemetrexed.
● For patients other than squamous cell carcinoma, continue with bevacizumab plus pemetrexed after 4-6 weeks of bevacizumab, pemetrexed, and cisplatin/carboplatin.
● Continuation of gemcitabine after 4-6 weeks of platinum-two-drug chemotherapy.
Switching maintenance: Two studies have shown that starting pemetrexed or erlotinib after first-line chemotherapy provides a benefit in progression-free survival and overall survival for patients without disease progression after 4-6 weeks of treatment.
● For patients other than squamous cell carcinoma, pemetrexed was initiated after 4-6 weeks of first-line platinum doublet chemotherapy.
● Initiate erlotinib after 4-6 weeks of first-line platinum two-drug chemotherapy.
● For patients with squamous cell carcinoma, start docetaxel after 4-6 weeks of first-line platinum doublet chemotherapy.
● Close monitoring of untreated patients may be an option as an alternative to maintenance therapy.
Subsequent treatment
Patients experiencing disease progression on or after first-line therapy may be treated with single-agent docetaxel, pemetrexed, or erlotinib in second-line therapy.
● Docetaxel is superior to vincristine or isocyclophosphamide.
● In patients with adenocarcinoma and large cell carcinoma, pemetrexed is similar to docetaxel and is less toxic.
● Ramucirumab in combination with docetaxel improves survival compared with docetaxel alone.
● Erlotinib is superior to best supportive care.
● Afatinib is indicated for patients with EGFR-sensitive mutations.
● Ceritinib is indicated for patients with ALK rearrangements who have disease progression or are intolerant to crizotinib.
Treatment after disease progression
For patients with EGFR-sensitive mutations or ALK rearrangements who have produced objective remission with targeted agents, prior agents other than targeted agents (erlotinib, gefitinib, afatinib, crizotinib, cretinoin) should not be continued after disease progression, except in established circumstances.