The National Comprehensive Cancer Network (NCCN) has made a series of updates to their treatment algorithm for non-small cell lung cancer (NSCLC).
In the diagnostics sections, a few screening and staging revisions were made. “Lung nodules in asymptomatic, high-risk patients detected during lung cancer screening with low-dose CT, see the NCCN Guidelines for Lung Cancer Screening” was moved to the algorithm. Additionally, the guidelines recommend that patients undergo invasive mediastinal staging (mediastinoscopy) before planned resection. “For patients undergoing EBUS/EUS staging, this may require a separate procedure to allow evaluation if onsite rapid cytology interpretation is not available,” the guideline reads.
For NSCLC with multiple lesions and T790M-positive histology, the option for PD-L1 expression positive was removed. Additionally, the guidelines suggest considering osimertinib (regardless of T790M status) or pulse erlotinib for progressive leptomeningeal disease. “The data in the second-line setting suggest that immunotherapy is less effective, irrespective of PD-L1 expression, in tumors with an actionable mutation,” the guidelines add.
For ALK rearrangement positive disease with systemic multiple lesions, the option for PD-L1 expression positive was removed. Similarly, the option for PD-L1 expression positive was removed for systemic isolated lesions. Multiple footnotes were added to this section, including “Beware of flare phenomenon in a subset of patients who discontinue ALK inhibitor. If disease flare occurs, restart ALK inhibitor” and “If considering WBRT, switch ALK inhibitor before using WBRT.”
In ROS1 rearrangement positive disease, a few edits were made to the first-line therapy options; ceritinib was added as a treatment option and crizotinib is now listed as a preferred treatment option. After progression on first-line therapy, the option for PD-L1 expression positive was removed.
In the section for principles of radiation therapy, a few bullets were modified for locally advanced stage II-III disease as well as metastatic stage IV disease. Concurrent chemotherapy and radiotherapy is now recommended for patients with inoperable stage II (node positive) and stage III disease followed by consolidation durvalumab for stage III disease. In advanced metastatic disease, the following sentence was added: “A randomized phase II trial of local consolidative therapy (radiotherapy or surgery) to oligometastatic lesions vs maintenance systemic therapy or observation for patients not progressing on systemic therapy found significantly improved progression-free survival for local consolidative therapy.”
Additions were also made to chemotherapy regimens for neoadjuvant and adjuvant therapy. For patients with comorbidities or those not able to tolerate cisplatin, the following regimens were added:
- · Carboplatin AUC 5 day 1, gemcitabine 1000 mg/m2 days 1, 8, every 21 days for 4 cycles
- · Carboplatin AUC 5 day 1, pemetrexed 500 mg/m2 days 1 for non-squamous every 21 days for 4 cycles
For patients receiving sequential chemotherapy and radiotherapy regimens in the adjuvant setting, the following regimens were removed:
- · Cisplatin 100 mg/m2 on days 1 and 29; vinblastine 5 mg/m2 weekly on days 1, 8, 15, 22, and 29; followed by radiotherapy
- · Paclitaxel 200 mg/m2 over 3 hours on day 1; carboplatin AUC 6 over 60 minutes on day 1 every 3 weeks for cycles 2 followed by thoracic radiotherapy
In the emerging targeted agents for patient with genetic alterations section, patients with HER2 mutation now have ado-trastuzumab emtansine available. For these same patients, trastuzumab and afatinib were both removed as viable options.—Zachary Bessette