Overview of the treatment of advanced non-small cell lung cancer
- Rogerio C Lilenbaum, MD, FACP
Rogerio C Lilenbaum, MD, FACP
- Section Editor — Lung Cancer
- Yale Cancer Center
- Section Editors
- Steven E Schild, MD
Steven E Schild, MD
- Section Editor — Radiation Therapy
- Professor of Radiation Oncology
- Mayo Clinic College of Medicine
- Howard J West, MD
Howard J West, MD
- Section Editor — Lung Cancer
- Medical Director
- Thoracic Oncology Program
- Swedish Cancer Institute (Seattle)
Treatment of patients with lung cancer depends upon the cell type (non-small cell versus small cell), tumor stage, molecular characteristics, and an assessment of the patient's overall medical condition. (See "Overview of the initial evaluation, treatment and prognosis of lung cancer".)
Patients with stage I, II, or III non-small cell lung cancer (NSCLC) are generally treated with curative intent using surgery, chemotherapy, radiation therapy (RT), or a combined modality approach (table 1). (See "Management of stage I and stage II non-small cell lung cancer" and "Management of stage III non-small cell lung cancer".)
Systemic therapy is generally indicated for patients who present with advanced disease, including those who present with metastases (stage IV) or recur following initial definitive treatment. For patients with a solitary metastasis, surgical resection or definitive irradiation of the metastasis may be appropriate. Systemic therapy and/or metastasectomy is also used for patients who have relapsed with advanced disease following prior definitive treatment. (See "Oligometastatic non-small cell lung cancer".)
This topic presents an overview of the management of patients with advanced NSCLC. More detailed discussions of specific issues are presented in the relevant topics, as indicated below.
The goals of patient management for patients with advanced NSCLC are to prolong survival and to maintain the quality of life for as long as possible, while minimizing the side effects due to treatment. The approach should recognize the palliative intent of treatment.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- NCCN guidelines http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#site.
- Kerr KM, Bubendorf L, Edelman MJ, et al. Second ESMO consensus conference on lung cancer: pathology and molecular biomarkers for non-small-cell lung cancer. Ann Oncol 2014; 25:1681.
- Lindeman NI, Cagle PT, Beasley MB, et al. Molecular testing guideline for selection of lung cancer patients for EGFR and ALK tyrosine kinase inhibitors: guideline from the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology. Arch Pathol Lab Med 2013; 137:828.
- Herbst RS, Baas P, Kim DW, et al. Pembrolizumab versus docetaxel for previously treated, PD-L1-positive, advanced non-small-cell lung cancer (KEYNOTE-010): a randomised controlled trial. Lancet 2016; 387:1540.
- Langer CJ, Gadgeel SM, Borghaei H, et al. Carboplatin and pemetrexed with or without pembrolizumab for advanced, non-squamous non-small-cell lung cancer: a randomised, phase 2 cohort of the open-label KEYNOTE-021 study. Lancet Oncol 2016; 17:1497.
- Reck M, Rodríguez-Abreu D, Robinson AG, et al. Pembrolizumab versus Chemotherapy for PD-L1-Positive Non-Small-Cell Lung Cancer. N Engl J Med 2016; 375:1823.
- Howell GM, Carty SE, Armstrong MJ, et al. Outcome and prognostic factors after adrenalectomy for patients with distant adrenal metastasis. Ann Surg Oncol 2013; 20:3491.
- Porta R, Sánchez-Torres JM, Paz-Ares L, et al. Brain metastases from lung cancer responding to erlotinib: the importance of EGFR mutation. Eur Respir J 2011; 37:624.
- Sperduto PW, Kased N, Roberge D, et al. Summary report on the graded prognostic assessment: an accurate and facile diagnosis-specific tool to estimate survival for patients with brain metastases. J Clin Oncol 2012; 30:419.
- Morris PG, Reiner AS, Szenberg OR, et al. Leptomeningeal metastasis from non-small cell lung cancer: survival and the impact of whole brain radiotherapy. J Thorac Oncol 2012; 7:382.
- Wagner H Jr. Just enough palliation: radiation dose and outcome in patients with non-small-cell lung cancer. J Clin Oncol 2008; 26:3920.
- Jeremić B, Videtic GM. Chest reirradiation with external beam radiotherapy for locally recurrent non-small-cell lung cancer: a review. Int J Radiat Oncol Biol Phys 2011; 80:969.
- Fairchild A, Harris K, Barnes E, et al. Palliative thoracic radiotherapy for lung cancer: a systematic review. J Clin Oncol 2008; 26:4001.
- Kelley AS, Meier DE. Palliative care--a shifting paradigm. N Engl J Med 2010; 363:781.
- Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010; 363:733.
- GENERAL APPROACH
- INITIAL SYSTEMIC THERAPY
- Driver mutation absent
- - Low or intermediate PD-L1 expression
- Initial therapy
- Maintenance therapy
- - High PD-L1 expression
- Driver mutation status unknown
- Driver mutation present
- - EGFR mutation positive
- - ALK fusion oncogene positive
- - Other mutations
- SUBSEQUENT TREATMENT
- ELDERLY AND POOR PERFORMANCE STATUS PATIENTS
- No driver mutation
- Driver mutation present
- MANAGEMENT OF SPECIFIC METASTATIC SITES
- Oligometastatic disease
- Bone metastases
- - Treatment
- - Prevention of complications
- Central nervous system metastases
- - Brain metastases
- - Leptomeningeal metastases
- SYMPTOM PALLIATION
- PALLIATIVE CARE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS