Non small cell lung cancer medical therapy
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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]
Overview
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.[1]
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 | |||||||||||||||||||||||||||||||||||||||||||||||
Chemotherapeutic regimens
Shown below is a table depicting the different choices of regimens for the initial or adjuvant chemotherapy of patients with non-small cell lung cancer. The list of regimens has been adapted from the 2014 NCCN Non-Small Cell Lung Cancer guidelines.[1]
Cisplatin based therapy
Agent | Recommended regimen |
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Cisplatin 50 mg/m2 + vinorelbine 25 mg/m2 | Cisplatin on days 1 and 8, vinorelbine on days 1, 8, 15, 22 and every 28 days to a total of 4 cycles |
Cisplatin 100 mg/m2 + vinorelbine 30 mg/m2 | Cisplatin on day 1, vinorelbine on days 1, 8, 15, 22 and every 28 days to a total of 4 cycles |
Cisplatin 75-80 mg/m2 + vinorelbine 25-50 mg/m2 | Cisplatin on day 1, vinorelbine on days 1, 8 and every 21 days to a total of 4 cycles |
Cisplatin 80 mg/m2 + vinorelbine 4 mg/m2 | Cisplatin on days 1, 22, 43, 64, then every 21 days to a total of 4 cycles, vinorelbine on days 1, 8, 15, 22, 29, every 2 weeks after day 43 until the completion of cisplatin treatmet |
Cisplatin 100 mg/m2 + etoposide 100 mg/m2 | Cisplatin on day 1, etoposide through days 1 to 3 and every 28 days to a total of 4 cycles |
Cisplatin 75 mg/m2 + gemcitabine 1250 mg/m2 | Cisplatin on day 1, gemcitabine on days 1, 8 and every 21 days to a total of 4 cycles |
Cisplatin 75 mg/m2 + docetaxel 75 mg/m2 | Cisplatin on day 1, docetaxel on day 1 and every 21 days to a total of 4 cycles |
Cisplatin 50 mg/m2 + pemetrexed 500 mg/m2 | Cisplatin on day 1, pemetrexed on days 1 and every 21 days to a total of 4 cycles |
Alternative regimen: patients with comorbidities or can't tolerate cisplatin
Paclitaxel 200 mg/m2 on day 1 + carboplatin area under the concentration (AUC) 6 on day 1 and then every 21 days.[1]
Chemotherapy plus radiotherapy regimens
Chemotherapy plus radiotherapy
The list bellow show the options for concomitant chemotherapy plus radiation therapy based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.[1]
- Cisplatin 50 mg/m2 on days 1, 8, 29 and 36 + etoposide 50 mg/m2 through days 1 to 5 and then 29 to 33 + thoracic radiotherapy
- Cisplatin 100 mg/m2 on days 1 and 29 + vinblastin 5 mg/m2 weekly for 5 weeks + thoracic radiotherapy
- Cisplatin 75 mg/m2 on the first day + pemetrexed 500 mg/m2 on day 1 and then every 21 days to a total of 3 cycles + thoracic radiotherapy
- Carboplatin (AUC) 5 on the first day + pemetrexed 500 mg/m2 on day 1 and then every 21 days to a total of 3 cycles + thoracic radiotherapy