Printed May 24, 2013 from http://www.cancer.net/publications-and-resources/what-know-ascos-guidelines/what-know-ascos-guideline-chemotherapy-stage-iv-non-small-cell-lung-cancer/recommendations

Recommendations

ASCO's recommendations for chemotherapy for stage IV NSCLC depend on the patient's performance status and whether a patient is receiving a first-line, second-line, or third-line treatment. ASCO recommends the following for all patients:

  • Any patient with good performance status (performance status 0, 1, and possibly 2) should be able to receive chemotherapy. Older patients should not be prevented from receiving chemotherapy based on age alone. Performance status and the patient's overall health are more important factors than age in considering chemotherapy as a treatment option.

ASCO recommends the following for patients receiving first-line treatment:

  • The most effective chemotherapy for most patients with performance status 0 and 1 is a combination of two drugs in which one is either carboplatin (Paraplat, Paraplatin) or cisplatin (Platinol). Cisplatin is slightly more effective, but has more side effects than carboplatin, so either is acceptable, depending on the doctor's and the patient's preferences. Types of chemotherapy that may be combined with cisplatin or carboplatin include docetaxel (Taxotere), gemcitabine (Gemzar), irinotecan (Camptosar), paclitaxel (Taxol), pemetrexed (Alimta), and vinorelbine (Navelbine).
  • Patients with a performance status of 2 may receive only one drug because there is not enough evidence to recommend taking more than one drug at a time. When a patient takes only one drug, it is typically not carboplatin or cisplatin, but rather one of the drugs commonly paired with carboplatin or cisplatin.
  • For patients with a performance status of 3 (in bed or a chair more than half the day), chemotherapy has not been shown to improve quality or length of life and may cause harmful side effects that could worsen a patient's quality of life. In this situation, patients should concentrate on supportive care to improve symptoms and take chemotherapy only with special caution.
  • Once a patient starts chemotherapy, treatment should be changed if it causes dangerous or difficult side effects. Chemotherapy should be stopped if the cancer grows, or if after four cycles, the cancer is stable but treatment is not causing the tumor to shrink. Two drug combinations should be given for no more than six cycles (up to five months). For patients with stable disease or cancer that is responding to treatment after four cycles, the doctor may consider immediately starting treatment with another drug, such as pemetrexed (patients with non-squamous cell carcinoma), docetaxel, or erlotinib. Or, the doctor might wait to start second-line chemotherapy until the cancer starts to grow again.
  • Most patients should not receive the drugs gefitinib or erlotinib as part of their first-line treatment.
  • However, some patients may receive either of these drugs and other targeted treatments as part of their first-line chemotherapy.
    • Erlotinib (or gefitinib for patients outside the United States) alone may be recommended for patients with tumors that have a mutation (change) in the epidermal growth factor receptor (EGFR) gene, which can be detected by testing the piece of lung cancer removed during a biopsy (removal of a small amount of tissue for examination under a microscope).
    • For patients receiving cisplatin and vinorelbine, cetuximab may be added.
    • Bevacizumab may be added to carboplatin and paclitaxel, except for patients who have a specific type of NSCLC called squamous cell carcinoma, or who have a history of coughing up blood, or have had a recent heart attack, blood clot, stroke, or bleeding, or brain metastases.

ASCO recommends the following for second-line treatment for patients with stage IV NSCLC:

  • Patients can receive one of the following drugs: docetaxel, erlotinib, gefitinib, or pemetrexed, when the first treatment is no longer effective. There is no evidence that combining treatments is effective or safe for second-line treatment, nor is there enough data to recommend how long a patient should receive a drug.

For patients receiving a third-line treatment, ASCO recommends the following:

  • For patients with a performance status of 0 to 3, erlotinib is recommended, as long as they have not previously received this drug or gefitinib. There is not enough evidence to make a recommendation for or against other types of chemotherapy for third-line treatment.

Lastly, ASCO recognizes that most patients with NSCLC may not have any special molecular tests, such as one to detect an EGFR mutation, performed on their tumor. These molecular tests remain investigational, and selecting treatment based on molecular tests has not been shown to improve a patient's overall length of life. Therefore, ASCO does not recommend using any routine molecular analysis of tumor tissue to guide treatment decisions at this time. For patients with an EGFR mutation, erlotinib or gefitinib may be the best first-line therapy, but may also work well as a second or third-line treatment.

To aid future research, ASCO recommends that doctors obtain a larger tissue sample when performing a biopsy so that the samples can be tested, which may be required for patients to participate in some types of clinical trials.