Non small cell lung cancer medical therapy metastatic cancer

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D. [2]

Medical Therapy for Metastatic Non-Small Cell Lung Cancer

What the specific subtype according to the specific histological characteristics of the tumor?

Adenocarcinoma Large cell carcinoma of the lung Not specified non-small cell lung cancer

Squamous cell carcinoma

Perform specific EGFR and ALK mutation testing: What is the specific mutation?

Is the patient a smoker or former smoker?

Sensitizing EGFR mutation

ALK mutation

Negative EGFR and ALK

Click here for the squamous cell carcinoma specific treatment

Click here for the sensitizing EGFR mutation specific treatment

Click here for the specific therapy for the ALK mutation specific treatment

Click here for the treatment of negative sensitizing EGFR and ALK mutation metastatic disease

Metastatic adenocarcinoma, large cell carcinoma and not specified non-small cell carcinoma

The algorithms for the treatment of metastatic non small cell carcinoma of the lung are based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.

Positive sensitizing EGFR mutation

Was the mutation discovered before the initiation of first line therapy?

Yes

No

Initiate erlotinib or afatinib

Suspend or complete chemotherapy and initiate erlotinib or afatinib OR Add erlotinib or afatinib to chemotherapy regimen

Did the tumor progress or respond?

Tumor progression

Positive response or stable tumor

Symptomatic disease

Asymptomatic disease

Systemic metastasis

Brain metastasis

Continue treatment

Multiple metastasis

Single metastasis

Multiple metastasis

Single metastasis

Continue treatment, consider local therapy

Continue treatment, consider whole brain radiation therapy

Continue treatment, consider local therapy

Consider platinum doublet with or without Bevacizumab AND/OR Erlotin

If findings suggestive of progression of the disease are present, click here for the third line therapy

Positive ALK mutation

Was the mutation discovered before the initiation of first line therapy?

Yes

No

Initiate crizotinib

Suspend or complete chemotherapy and initiate crizotinib

Did the tumor progress or respond?

Tumor progression

Positive response or stable tumor

Symptomatic disease

Asymptomatic disease

Systemic metastasis

Brain metastasis

Continue treatment or change to certinib according to the degree of disease

Multiple metastasis

Single metastasis

Multiple metastasis

Single metastasis

Continue treatment, consider local therapy

Continue treatment, consider whole brain radiation therapy

Continue treatment, consider local therapy

Initiate certinib OR Consider platinum doublet with or without Bevacizumab AND/OR Erlotinib

If findings suggestive of progression of the disease are present, click here for the third line therapy

Negative EGRF and ALK or unknown mutation

What is the performance status (PS) of the patient?

0-1

2

3-4

Doublet chemotherapy OR Bevacizumab + Chemotherapy OR Cetuximab/vinorelbine/cisplatin

Chemotherapy

Supportive care

What was the tumor response to the treatment?

Progression

Positive response or stable tumor

Administer 4-6 cycles and assess progression of the disease

PS 0-2

PS 3-4

Tumor progression

Positive response or stable tumor

Initiate docetaxel or pemetrexed or erlotinib or gemcitabine

Provide supportive care

Initiate docetaxel or pemetrexed or erlotinib or gemcitabine

Continuation maintenance (cetuximab or gemcitabine) OR Switch maintenance (erlotinib or decetaxel) OR Close observation

Initiate docetaxel or pemetrexed or erlotinib or gemcitabine

If findings suggestive of progression of the disease are present, click here for the third line therapy

Metastatic squamous cell carcinoma

What is the performance status (PS) of the patient?

0-1

2

3-4

Doublet chemotherapy OR Cetuximab/vinorelbine/cisplatin

Chemotherapy

Suportive care

What was the tumor response to the treatment?

Progression

Positive response or stable tumor

Administer 4-6 cycles and assess progression of the disease

PS 0-2

PS 3-4

Tumor progression

Positive response or stable tumor

Initiate docetaxel or erlotinib or gemcitabine

Provide suportive care

Initiate docetaxel or erlotinib or gemcitabine

Continuation mantainance (cetuximab or gemcitabine) OR Switch mantainance (erlotinib or decetaxel) OR Close observation

Initiate docetaxel or pemetrexed or erlotinib or gemcitabine

If findings suggestive of progression of the disease are present, click here for the third line therapy