Lung Cancer

Treatment First-Line Chemotherapy ÎEvidence supports use of chemotherapy in patients with stage IV* non–small- cell lung cancer (NSCLC) with ECOG/Zubrod PS-0, 1, possibly 2. [*As defined by the International Association for the Study of Lung Cancer Staging Project, for the 7th edition of the TNM Classification of Malignant tumors] ÎEvidence does not support selection of specific first-line chemotherapy drug or combination based on age alone. ÎIn patients with PS-0 or 1, evidence supports using a combination of two cytotoxic drugs for first-line therapy. • Platinum combinations are preferred over nonplatinum combinations because they are superior in response rate and marginally superior in overall survival (OS). • Nonplatinum therapy combinations are reasonable in patients who have contraindications to platinum therapy. • Choice of either cisplatin or carboplatin is acceptable. • Drugs that may be combined with platinum include third-generation cytotoxic drugs docetaxel, gemcitabine, irinotecan, paclitaxel, pemetrexed, and vinorelbine. • Evidence suggests cisplatin combinations result in higher response rates than carboplatin and may improve survival when combined with third-generation agents. • Carboplatin is less likely to cause nausea, nephrotoxicity, and neurotoxicity than cisplatin but more likely to cause thrombocytopenia. Note: Data are insufficient to make a recommendation for or against using a combination of two cytotoxic drugs in patients with PS-2. ÎBevacizumab and cetuximab • Based on one large Phase III randomized clinical trial (RCT), the update committee recommends addition of bevacizumab (15 mg/kg every 3 weeks) to carboplatin/ paclitaxel, except for patients with squamous cell carcinoma histologic type, brain metastases, clinically significant hemoptysis, inadequate organ function, ECOG PS > 1, therapeutic anticoagulation, clinically significant cardiovascular disease, or medically uncontrolled hypertension. Note: Bevacizumab should be continued as tolerated until disease progression. • Based on one large Phase III RCT, clinicians may consider addition of cetuximab to cisplatin/vinorelbine in first-line therapy in patients with epidermal growth factor receptor (EGFR)-positive tumor as measured by immunohistochemistry (IHC). Note: Cetuximab may be continued as tolerated until disease progression. ÎAvailable data support use of single-agent chemotherapy in patients with PS-2. ÎIn patients with stage IV NSCLC, first-line cytotoxic chemotherapy should be stopped at disease progression or after four cycles in patients whose disease is stable but not responding to treatment. ÎTwo-drug cytotoxic combinations should be administered for no more than six cycles.

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