Chest
Treatment of Stage IV Non-small Cell Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
Section snippets
General Approach
2.1.1. In patients with a good performance status (PS) (ie, Eastern Cooperative Oncology Group [ECOG] level 0 or 1) and stage IV non-small cell lung cancer (NSCLC), a platinum-based chemotherapy regimen is recommended based on the survival advantage and improvement in quality of life (QOL) over best supportive care (BSC). (Grade 1A).
Remark: Patients may be treated with several chemotherapy regimens (carboplatin and cisplatin are acceptable, and can be combined with paclitaxel, docetaxel,
Methods
A writing committee was assembled and approved according to ACCP policies as described in the methodology article of the lung cancer guidelines.1 This committee, in conjunction with the executive committee, formulated clinical questions in a PICO format (Table S1), and the search and study selection was structured around these questions. The primary questions are summarized below:
- 1.
Should the choice of first-line chemotherapy be based on histology in patients with advanced stage IV NSCLC?
- 2.
General Approach to Patients
General aspects of the approach to patients with stage IV NSCLC were discussed in the first and second editions of the ACCP Lung Cancer Guidelines3, 4 and are summarized here only briefly. The rationale, arguments, and data regarding this have not changed substantially from these earlier editions.
The goal of the treatment of patients with stage IV NSCLC is palliation, both through improvement in quality of life (QOL) and in prolongation of survival. Both the patients and the physicians involved
Histology-Based Chemotherapy Selection
PICO 1: Should the choice of first-line chemotherapy be based on histology in patients with advanced stage IV NSCLC?
NSCLC can be subdivided into three broad histologic subtypes: adenocarcinoma, accounting for roughly 45% of NSCLC; squamous cell carcinoma, accounting for approximately 23%; and large cell carcinoma, accounting for 3% (with the remaining cases not meeting the criteria for any of these categories).8, 9 Historically, histology was not a consideration in chemotherapy choice, which
Second- and Third-Line Chemotherapy
PICO 6: Will second-/third-line chemotherapy lead to better survival than no second-/third-line chemotherapy for patients with advanced stage IV NSCLC with prior therapy?
Three randomized trials have compared treatment with second- or third-line therapy and BSC in patients with previously treated advanced stage IV NSCLC.63, 78, 79 The first trial to identify a survival benefit with second-line therapy compared single-agent docetaxel and BSC.78 Two subsequent trials have been published comparing
Treatment of Elderly Patients
PICO 7: Is doublet chemotherapy more effective than single-agent chemotherapy for patients > 70 years of age with advanced stage IV NSCLC?
In the second addition of the ACCP clinical practice guidelines, single-agent chemotherapy was recommended for most patients with stage IV NSCLC who were aged 70 to 79 years.4 However, two-drug combinations were recommended as an option for patients with a good PS and a lack of significant comorbidities. In 2010, the European Organization of Research and
Treatment of Patients With Poor PS
PICO 8: Is doublet chemotherapy more effective than single-agent chemotherapy for patients with a PS of 2 with advanced stage IV NSCLC?
PS is an important prognostic factor for patients with advanced NSCLC.111, 112, 113, 114 The ECOG 1594 trial randomly assigned patients to one of four platinum-based double-agent chemotherapy regimens. The Data Monitoring Committee observed an excessive rate of adverse events among the patients with a PS of 2 and recommended discontinuation of enrollment of
The Role of Palliative Care in Stage IV NSCLC
PICO 9: Is palliative care more effective in improving survival than no palliative care for patients with advanced stage IV NSCLC?
For patients with advanced cancer, heavy symptom burden, psychosocial stressors, and fears of death are not relegated only to the illness's terminal phase, and patients with such issues may still have much to gain from systemic anticancer treatments. Specific symptoms are addressed in detail in the article, “Symptom Management in Patients With Lung Cancer,” of the
Conclusion
Stage IV NSCLC is a treatable disease. Articles addressing stage IV NSCLC in previous editions of the ACCP lung cancer guidelines3, 4 have provided evidence supporting this statement. In this third edition, several new issues have been addressed. Histology has become a pivotal determinant of therapeutic choice in this setting. Also, the presence of an EGFR sensitizing mutation identifies patients with stage IV NSCLC who would benefit more from an EGFR TKI than from standard platinum-based
Acknowledgments
Author contributions: Dr Socinski had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Dr Socinski: contributed to the development of the article, including the data analysis and subsequent development of the recommendations contained herein, and as topic editor.
Dr Evans: contributed as topic editor and panelist.
Dr Gettinger: contributed as topic editor and panelist.
Dr Hensing: contributed as topic editor
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Funding/Sponsors: The overall process for the development of these guidelines, including matters pertaining to funding and conflicts of interest, are described in the methodology article.1 The development of this guideline was supported primarily by the American College of Chest Physicians. The lung cancer guidelines conference was supported in part by a grant from the Lung Cancer Research Foundation. The publication and dissemination of the guidelines was supported in part by a 2009 independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc.
COI Grids reflecting the conflicts of interest that were current as of the date of the conference and voting are posted in the online supplementary materials.
Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://dx.doi.org/10.1378/chest.1435S1.
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.