National Comprehensive Cancer Network

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UPDATES: NCCN Guidelines® and NCCN Compendium®

NCCN Flash Update sent October 14, 2013

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Non-Small Cell Lung Cancer. These NCCN Guidelines® are currently available as Version 1.2014.

  • Stage IB, I, II, IIB; treatment recommendations modified for medically inoperable. (NSCL-2)
    • Nodal status added
      • N0 is recommended to receive definitive RT including SABR, followed by adjuvant chemotherapy for high-risk stages IB-II.
      • N1 is recommended to receive definitive chemoradiation. (NSCL-3)

 

  • Stage IIA, IIB, margins positive; adjuvant treatment recommendations modified.
    • R1 resection separated out with the following recommendations: resection + chemotherapy or chemoradiation (sequential or concurrent).
    • R2 resection separated out with the following recommendations: resection + chemotherapy or concurrent chemoradiation.

 

  • Stage IIIA; adjuvant treatment recommendations modified. (NSCL-3)
    • R0 resection clarified as chemotherapy (category 1) or sequential chemotherapy + RT (N2 only).
    • R1 resection separated out with the following recommendations: chemoradiation (sequential or concurrent).
    • R2 resection separated out with the following recommendations: concurrent chemoradiation.

 

  • Chest wall, proximal airway, or mediastinum (T3 invasion, N0-1; resectable T4 extension, N0-1) (NSCL-6)
    • Surgery as initial treatment, margins positive:
      • R1 resection separated out with the following recommendations: resection + chemotherapy or chemoradiation (sequential or concurrent).
      • R2 resection separated out with the following recommendations: resection + chemotherapy or concurrent chemoradiation.

 

  • T1-3, N0-1 (including T3 with multiple nodules in same lobe) (NSCL-8) and Separate pulmonary nodules, same lobe (T3, N0), or ipsilateral non-primary node (T4, N0) (NSCL-9)
    • Surgery as initial treatment, margins positive:
      • R1 resection separated out with the following recommendations: chemoradiation (sequential or concurrent).
      • R2 resection separated out with the following recommendations: concurrent chemoradiation.

 

  • Mediastinal lymph node recurrence (NSCL-15)
    • Treatment recommendations listed according to prior treatment with RT. If patients received prior RT, the recommendation of systemic chemotherapy added.

 

  • Metastatic disease (NSCL-16)
    • Establish histologic subtype with adequate tissue for molecular testing: “consider rebiopsy if appropriate” added.
    • Adenocarcinoma, large cell, NSCLC NOS; the following added:
      • Category 1 added to ALK testing.
      • EGFR ± ALK testing should be conducted as part of a multiplex/next-generation sequencing.
    • Squamous cell carcinoma; the following modified/added:
      • Consider EGFR mutation and ALK testing are not routinely recommended except especially in never smokers and or small biopsy specimens, or mixed histology.
      • EGFR ± ALK testing should be conducted as part of a multiplex/next-generation sequencing.

 

  • Adenocarcinoma, large cell, NSCLC NOS: sensitizing EGFR mutation positive (NSCL-17)
    • First-line therapy, EGFR mutation discovered prior to first-line chemotherapy: afatinib added as a category 1 recommendation.
    • First-line therapy, EGFR mutation discovered during first-line chemotherapy: recommended treatment options modified to, “Interrupt or complete planned chemotherapy, start erlotinib or afatinib or May add erlotinib or afatinib to current chemotherapy (category 2B.)
    • Second-line therapy: afatinib added as a treatment option.
    • Second-line therapy, symptomatic brain: footnote ll added: “Consider pulse erlotinib for carcinomatosis meningitis.”
    • Second-line therapy, systemic multiple lesions: Consider systemic therapy changed to Consider platinum doublet ± bevacizumab ± erlotinib.
    • Footnote mm added: “Afatinib appears to have some efficacy in patients who progressed on EGFR therapy. Mazieres J, Peters S, Lepage B, et al. Lung cancer that harbors an HER2 mutation: epidemiologic characteristics and therapeutic perspectives. J Clin Oncol 2013;31:1997-2003.”

 

  • Adenocarcinoma, large cell, NSCLC NOS: ALK positive (NSCL-18)
    • Treatment recommendations for ALK positive modified to be consistent with EGFR-positive mutations.

 

  • Adenocarcinoma, large cell, NSCLC NOS: EGFR mutation and ALK negative or unknown (NSCL-19)
    • First-line therapy: the combination regimen cisplatin/pemetrexed was deleted from this page, as it is included in doublet chemotherapy.
    • Maintenance therapy:
      • Continuation of current regimen until disease progression removed as an option.
      • Continuation maintenance with gemcitabine changed from a category 2A recommendation to a category 2B recommendation.
      • Switch maintenance with pemetrexed or erlotinib changed from a category 2A recommendation to a category 2B recommendation.
    • Footnote nn added: “Consider additional mutational testing if only EGFR and ALK were performed. See Targeted Agents for Patients with Other Genetic Alterations” (NSCL-H).
    • Second-line therapy
      • The following qualifying statement added: “if not already given”
      • Gemcitabine added as a treatment option.

 

  • Squamous cell carcinoma (NSCL-20)
    • Maintenance therapy:
      • The following was removed as an option: “Continuation of current regimen until disease progression”
      • Continuation maintenance with gemcitabine changed from a category 2A recommendation to a category 2B recommendation.
      • Switch maintenance with docetaxel or erlotinib changed from a category 2A recommendation to a category 2B recommendation.
    • Second-line therapy
      • The following qualifying statement added: “if not already given”
      • Gemcitabine added as a treatment option.

 

  • Adenocarcinoma, large cell, NSCLC NOS, or squamous cell carcinoma (NSCL-21)
    • Third-line therapy: Gemcitabine added as an option.
    • Footnote ss is new to the page: “Pemetrexed, docetaxel, and gemcitabine are category 2B if patient did not receive erlotinib or crizotinib in first- or second-line therapy.”

 

  • Chemotherapy regimens used with radiation therapy (NSCL-E)
    • Concurrent chemotherapy/RT followed by chemotherapy: Weekly paclitaxel/carboplatin regimen changed from a category 2B to a category 2A recommendation.

 

  • New page added listing targeted agents for patients with genetic alterations. (NSCL-H)

For the complete updated versions of the NCCN Guidelines, the NCCN Drugs & Biologics Compendium (NCCN Compendium®, and the NCCN Chemotherapy Order Templates (NCCN Templates®), please visit NCCN.org.

To access the NCCN Biomarkers Compendium™, please visit NCCN.org/biomarkers.

To view the NCCN Guidelines for Patients®, please visit NCCN.org/patients.

Free NCCN Guidelines apps for iPad and Android tablets are now available! Visit NCCN.org/apps