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]

Metastatic adenocarcinoma

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.

Positive sensitizing EGRF 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 Erlotinib

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

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

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 pemetrexed or erlotinib or gemcitabine

Provide suportive care

Initiate docetaxel or pemetrexed 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

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 erlotinib or gemcitabine

Chemotherapeutic regimens

The table below is based on the 2014 NCCN Non-Small Cell Lung Cancer guidelines.

Agent	Recommended regimen
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 50mg/m2 + pemetrexed 500 mg/m2	Cisplatin on day 1, pemetrexed on days 1 and every 21 days to a total of 4 cycles

References

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