Treatment Of Stage IV Non-Small Cell Lung Cancer: Diagnosis And Management Of Lung Cancer
Publication Date: November 1, 2013
Last Updated: March 14, 2022
Recommendations
General Approach to Patients
In patients with a good PS (ie, ECOG level 0 or 1) and stage IV NSCLC, a platinum-based chemotherapy regimen is recommended based on the survival advantage and improvement in QOL over BSC. (1, A)
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In patients with stage IV NSCLC and a good PS, two-drug combination chemotherapy is recommended. The addition of a third cytotoxic chemotherapeutic agent is not recommended because it provides no survival benefit and may be harmful. (1, A)
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First-Line Chemotherapy
In patients receiving palliative chemotherapy for stage IV NSCLC, it is recommended that the choice of chemotherapy is guided by the histologic type of NSCLC. (1, B)
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In patients with known EGFR mutations and stage IV NSCLC, first-line therapy with an EGFR TKI (gefitinib or erlotinib) is recommended based on superior response rates, PFS and toxicity profiles compared with platinumbased doublets. (1, A)
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Bevacizumab improves survival combined with carboplatin and paclitaxel in a clinically selected subset of patients with stage IV NSCLC and good PS (nonsquamous histology, lack of brain metastases, and no hemoptysis). In these patients, addition of bevacizumab to carboplatin and paclitaxel is recommended. (1, A)
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In patients with stage IV non-squamous NSCLC and treated, stable brain metastases, who are otherwise candidates for bevacizumab therapy, the addition of bevacizumab to first-line, platinum-based chemotherapy is a safe therapeutic option. (2, B)
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In patients with stage IV non-squamous NSCLC who do not experience disease progression after 4 cycles of platinum-based therapy (which does not include pemetrexed), treatment with switch maintenance pemetrexed is suggested. (2, B)
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In patients with stage IV NSCLC, switch maintenance therapy with other chemotherapy agents other than pemetrexed has not demonstrated an improvement in overall survival and is not recommended. (1, B)
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In patients with stage IV non-squamous NSCLC who do not experience disease progression after 4 cycles of platinum-pemetrexed therapy, continuation pemetrexed maintenance therapy is suggested. (2, B)
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In patients with stage IV NSCLC who do not experience disease progression after 4 cycles of platinum-based double agent chemotherapy, maintenance therapy with erlotinib is suggested. (2, B)
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In patients with stage IV NSCLC the addition of cetuximab in combination with chemotherapy is suggested not to be used outside of a clinical trial. (2, B)
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Second- and Third-Line Chemotherapy
In patients with stage IV NSCLC who have good PS (ECOG 0-2), second-line treatment with erlotinib or docetaxel (or equivalent single-agent such as pemetrexed) is recommended. (1, A)
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In patients with stage IV NSCLC who have good PS (ECOG 0-2), third-line treatment with erlotinib improves survival compared with BSC and is recommended. (1, B)
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Treatment of Elderly Patients
In elderly patients (age 70–79 years) with stage IV NSCLC who have good PS and limited co-morbidities, treatment with the two drug combination of monthly carboplatin and weekly paclitaxel is recommended. (1, A)
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Treatment of Patients With Poor PS
For patients with stage IV NSCLC with a PS of 2 in whom the PS is caused by the cancer itself, double agent chemotherapy is suggested over single agent chemotherapy. (2, B)
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In patients with stage IV NSCLC who are an ECOG PS of 2 or greater, it is suggested not to add bevacizumab to chemotherapy outside of a clinical trial. (2, B)
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The Role of Palliative Care in Stage IV NSCLC
In patients with stage IV NSCLC early initiation of palliative care is suggested to improve both QOL and duration of survival. (2, B)
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Recommendation Grading
Overview
Title
Treatment Of Stage IV Non-Small Cell Lung Cancer: Diagnosis And Management Of Lung Cancer
Authoring Organization
American College of Chest Physicians
Publication Month/Year
November 1, 2013
Last Updated Month/Year
June 26, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
Stage IV non-small cell lung cancer (NSCLC) is a treatable, but not curable, clinical entity in patients given the diagnosis at a time when their performance status (PS) remains good.
Target Patient Population
Patients with Stage IV lung cancer
Inclusion Criteria
Female, Male, Adolescent, Adult, Older adult
Health Care Settings
Hospice, Hospital, Operating and recovery room, Outpatient, Radiology services
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management, Treatment
Diseases/Conditions (MeSH)
D002289 - Carcinoma, Non-Small-Cell Lung, D018787 - Radiation Oncology, D011827 - Radiation, D008175 - Lung Neoplasms, D017024 - Chemotherapy, Adjuvant
Keywords
lung cancer, non-small cell lung cancer, palliative care, Non Small Cell Lung Cancer, non_small_cell_lung_cancer