ASCO Updates Guideline for NSCLC Systemic Therapy

08/15/17

The American Society of Clinical Oncology (ASCO) has updated their guideline on systemic therapy for non-small cell lung cancer (NSCLC) for the first time since 2015.

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The updated guideline focuses on the appropriate use of immunotherapy and provides new recommendations for the use of targeted therapy for patients with stage IV NSCLC. Recommendations are centered on the use of immunotherapy in the first- and second-line settings, and targeted therapies for patients with abnormalities in tumor EGFR, ALK, and ROS1 genes. The updated guideline does not provide recommendations for immunotherapy in the third-line setting due to a lack of available evidence.

“Knowing when to use targeted therapies or immunotherapy in place of more toxic chemotherapy can help improve the quality of life of our patients,” said Gregory A Masters, MD, ASCO panel co-chair, in a press release (August 14, 2017).

The guidelines take into account data from 14 randomized clinical trials conducted between 2014 and 2016. First-line recommendations from the 2015 guideline are maintained for patients with EGFR, ALK, or, ROS1 mutations in their tumors. The following recommendations are included for patients in the first-line setting without EGFR, ALK, and ROS1 mutations:

  • Pembrolizumab alone is recommended for patients with high PD-L1 expression in the tumor;
  • Patients with low PD-L1 expression should be offered standard chemotherapy; and
  • All other checkpoint inhibitors, combinations of checkpoint inhibitors and immune checkpoint therapy with chemotherapy are not recommended.

Recommendations for second-line treatment include:

  • Single-agent nivolumab, pembrolizumab or atezolizumab is recommended for patients with high PD-L1 expression who have not received prior immunotherapy;
  • If PD-L1 expression is low or unknown, then nivolumab, atezolizumab or chemotherapy is recommended;
  • All other checkpoint inhibitors, combinations of checkpoint inhibitors, and immune checkpoint therapy with chemotherapy are not recommended;
  • Patients who received checkpoint inhibitors as first-line therapy should be offered standard chemotherapy;
  • Patients who cannot receive an immune checkpoint inhibitor after chemotherapy should be offered docetaxel; pemetrexed is recommended for patients with nonsquamous NSCLC;
  • Among patients with sensitizing EGFR mutations, those who progressed after first-line EGFR-targeted therapy and harbor a T790M mutation should receive osimertinib. If no T790M mutation is present, then standard chemotherapy should be offered;
  • Patients with ROS1 gene arrangement may be offered crizotinib if they have not previously received it. If patients received prior crizotinib therapy, chemotherapy should be offered; and
  • Concurrent palliative care should commence at diagnosis.

“This guideline update provides oncologists the tools to choose therapies that are most likely to benefit their patients,” commented Nasser Hanna, MD, co-chair of the ASCO expert panel.—Zachary Bessette