For patients in whom the EGFR mutation is discovered during chemotherapy, the guidelines recommend either adding erlotinib to the current chemotherapy protocol or switching to erlotinib as maintenance treatment."
For patients whose EGFR status is negative or unknown, even in the presence of clinical characteristics that might be suggestive of a mutation (for example, female, nonsmoker, Asian race), conventional chemotherapy is recommended, Dr. Ettinger said.
The updated NCCN guidelines for NSCLC are posted at www.nccn.org.
The guidelines take a conservative stance on the National Lung Screening Trial finding that screening with low-dose helical CT was associated with a 20% reduction in lung cancer deaths vs. screening with standard chest x-ray. Despite this positive finding, "the NCCN panel does not recommend the routine use of screening CT as a standard clinical practice," said Dr. Ettinger; more conclusive data from ongoing national trials are needed to define the associated risks and benefits. "High-risk patients should participate in a clinical trial evaluating CT screening or go to a center of excellence to discuss the potential risks and benefits of a screening CT," Dr. Ettinger said.
Other notable updates include the following:
• The addition of EBUS (endobronchial ultrasound) as a work-up recommendation.
• The recommendation that bevacizumab (Avastin) and chemotherapy or chemotherapy alone is indicated in performance status 0-1 patients with advanced or recurrent NSCLC, and that bevacizumab should be given until disease progression.
• The recommendation against systemic chemotherapy in performance status 3-4 NSCLC patients.
• The guidance that chemoradiation is better than chemotherapy alone in locally advanced NSCLC, and that concurrent chemoradiation is better than sequential chemoradiation.
• The addition of denosumab (Xgeva) as a treatment option for patients with bone metastases.
• The recommendation favoring cisplatin/pemetrexed (Alimta) vs. cisplatin/gemcitabine (Gemzar) in patients with nonsquamous histology.
• The recommendation against adding a third cytotoxic drug, with the exception of bevacizumab or cetuximab (Erbitux), in treatment-naive performance status 0-1 NSCLC patients.
• The guidance that cisplatin-based combinations are better than best supportive care in advanced, incurable disease, with improvement in median survival and 1-year survival rates.
The ASCO PCO is available online.
In an editorial that accompanied ASCO’s PCO announcement, Dr. Paul A. Bunn Jr. and Dr. Robert C. Doebele of the University of Colorado Cancer Center in Aurora wrote that the growing clinical importance of molecularly defined subgroups of adenocarcinoma signals a "new era of personalized medicine for patients with advanced lung cancer, in which it will be imperative to match the specific mutations of a patient’s tumor with a specific therapy."
The implementation of routine, simultaneous testing of multiple markers will likely be conducted on all patients prior to treatment initiation, regardless of clinical features, they stated, acknowledging certain procedural challenges, including obtaining adequate tumor material at the time of diagnostic biopsy and developing testing platforms "that simultaneously analyze for the presence of somatic mutations, gene fusions, or other genetic challenges."
Dr. Ettinger has consultancy agreements with the following companies: Biodesix, Boehringer Ingelheim, Daiichi Sankyo, Eli Lilly, Genentech, Merck, Novartis Pharmaceuticals, Poniard Pharmaceuticals, Prometheus Laboratories, Shin Nippon Biomedical Laboratories, and Telik. Dr. Keedy receives commercial research support from Ariad Pharmaceuticals, Ziopharm Oncology, and Amgen Oncology Therapeutics. Dr. Bunn has a consultant or advisory role with Amgen, AstraZeneca, Abraxis, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, GlaxoSmithKline, Syndax, Biodesix, Allos Therapeutics, Novartis, OSI/Genentech/Roche, Poniard, and Sanofi-Aventis. Dr. Doebele disclosed research funding from Lilly, ImClone Systems, and Pfizer.