ÎFor patients with stable disease or response after four cycles, consider immediate treatment with alternative, single-agent chemotherapy such as pemetrexed in patients with nonsquamous histology, docetaxel in unselected patients, or erlotinib in unselected patients.
Note: Limitations of this data are such that a break from cytotoxic chemotherapy after fixed course is also acceptable, with initiation of second-line chemotherapy at disease progression.
ÎIn unselected patients, erlotinib or gefitinib should NOT be used in combination with cytotoxic chemotherapy as first-line therapy.
• First-line use of erlotinib or gefitinib may be recommended for patients with activating EGFR mutations found in their tumor tissue.
• If EGFR mutation status is negative or unknown, cytotoxic chemotherapy is preferred. Note: In unselected patients, evidence is insufficient to recommend single-agent erlotinib or gefitinib as first-line therapy.
Second-Line Chemotherapy
ÎDocetaxel, erlotinib, gefitinib, or pemetrexed is acceptable as second-line therapy for patients with advanced NSCLC with adequate performance status when disease has progressed during or after first-line platinum- based therapy.
Note: Evidence does not support selection of a specific second-line chemotherapy drug or combination based on age alone.
Third-Line Chemotherapy
ÎWhen disease progresses on or after second-line chemotherapy, treatment with erlotinib may be recommended as third-line therapy for patients with PS-0 to 3 who have not received prior erlotinib or gefitinib.
Note: Data are not sufficient to make a recommendation for or against using cytotoxic drugs as third-line therapy. Patients should consider experimental treatment, clinical trials, and best supportive care.
Molecular Analysis
ÎOn the basis of the results of five phase III RCTs, patients with NSCLC who are being considered for first-line therapy with an EGFR tyrosine kinase inhibitor (TKI) (patients who have not previously received chemotherapy or an EGFR TKI) should have their tumor tested for EGFR mutations to determine whether an EGFR TKI or chemotherapy is appropriate first-line therapy (http://www.asco.org/pco/egfr).
ÎTo obtain tissue for more accurate histologic classification or for investigational purposes, the update committee supports reasonable efforts to obtain more tissue than that contained in a routine cytology specimen.
