What are the third-line treatment recommendations for non-small cell lung cancer (NSCLC) stage IV or recurrent disease?

Updated: Jul 15, 2021
  • Author: Marvaretta M Stevenson, MD; Chief Editor: Nagla Abdel Karim, MD, PhD  more...
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Answer

Answer

Third-line therapy is given for advanced or recurrent non–small cell lung cancer (NSCLC) after disease progression following first-line and second-line therapy. Options include erlotinib, ramucirumab, and nivolumab.

Erlotinib is indicated for patients with EGFR mutation or gene amplification. It is given in a dosage of 150 mg PO daily until disease progression. [7, 33, 73, 74, 75, 76, 77, 78, 79]

Ramucirumab is indicated for metastatic NSCLC with disease progression on or after platinum-based chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving ramucirumab. The regimen is as follows:

  • Ramucirumab 10 mg/kg IV infused over ~1 h prior to docetaxel (75 mg/m2) IV infusion on day 1 of a 21-d cycle; continue until disease progression or unacceptable toxicity [72]

Nivolumab is indicated for metastatic squamous and nonsquamous (including adenomas) NSCLC with progression on or after platinum-based chemotherapy. [71]

The regimen is as follows:

  • Nivolumab: 240 mg IV q2wk or 480 mg q4wk over 30 min; continue until disease progression or unacceptable toxicity

Pembrolizumab is indicated for metastatic NSCLC in patients whose tumors express PD-L1 and who have disease progression on or after platinum-containing chemotherapy. [68]  The regimen is as follows:

  • Pembrolizumab 200 mg IV q3wk or 400 mg IV q6wk; continue until disease progression or unacceptable toxicity (for up to 24 mo) [28]

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