ASCO issues specific recommendations for chemotherapy in stage IV NSCLC

The American Society of Clinical Oncology this week released new recommendations for chemotherapy use in patients with stage IV non–small cell lung cancer. The society recommended specific therapies for first-, second-, and third-line treatment in these patients and recommended that oncologists consider factors such as physiological age and performance status, rather than physical age alone, when determining treatment.

The ASCO panel for the guideline recommended that oncologists use a platinum-based two-drug combination of cytotoxic drugs for first-line therapy in patients with performance status of 0 or 1. It noted that platinum combinations are preferred because they provide superior response and a slightly superior OS; however, nonplatinum cytotoxic agents are acceptable for patients with contraindications to platinum therapy. The updated guideline also stated that a single cytotoxic drug is sufficient for patients with performance status of 2.

Specifically, the evidence-based guideline said that cisplatin or carboplatin be used for first-line chemotherapy in combination with docetaxel, gemcitabine, irinotecan, paclitaxel, pemetrexed (Alimta, Lilly) or vinorelbine. In certain instances, the ASCO panel recommended bevacizumab (Avastin, Genentech) with carboplatin plus docetaxel.

In patients with a tumor with an epidermal growth factor receptor protein, the ASCO panel recommended cetuximab (Erbitux, Imclone) with cisplatin plus vinorelbine. Finally, gefitinib (Iressa, AstraZeneca) may be used as first-line therapy for patients with a known EGFR gene mutation.

First-line cytotoxic chemotherapy should cease after disease progression or after four cycles with no response to treatment. Two-drug cytotoxic chemotherapy should be stopped after six cycles even in patients who respond.

Second- and third-line treatment

The panel recommended docetaxel, erlotinib, gefitinib or pemetrexed alone for second-line therapy. For third-line treatment, they recommended erlotinib (Tarceva, OSI Pharmaceuticals) for patients who have performance status of 0 to 3 and who have not previously received erlotinib or gefitinib.

The ASCO panel did not recommend routine use of molecular markers to choose treatment for patients because of a lack of data demonstrating a reduction in mortality with this approach. The panel also stated that data are insufficient to recommend routine third-line use of cytotoxic drugs.

This updated clinical practice guideline was based on 162 relevant randomized trials on chemotherapy and biologic therapy published since 2002. In the time since the guideline was submitted for publication, the FDA approved a new indication for pemetrexed as maintenance therapy in patients with advanced NSCLC. The panel is considering recently published relevant data regarding pemetrexed to update the recommendation on maintenance therapy.

The guideline, decision aid tools and other resources are available at www.asco.org/guidelines/nsclc.

Azzoli CG. J Clin Oncol. 2009;doi:10.1200/JCO.2009.23.5622.