What are the ASCO guidelines for systemic treatment of stage IV non–small cell lung cancer (NSCLC)?

Updated: Jul 15, 2021
  • Author: Winston W Tan, MD, FACP; Chief Editor: Nagla Abdel Karim, MD, PhD  more...
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The American Society of Clinical Oncology (ASCO) published its most recent full update of guidelines on systemic therapy for stage IV NSCLC in 2017. [220]  ASCO and Ontario Health (Cancer Care Ontario)(OH[CCO]) published a partial update on treatment of stage IV NSCLC without driver alterations in 2020. [221] In addition, ASCO recommends early palliative care assistance for all patients with stage IV NSCLC, because it improves survival and well-being in patients with this incurable condition. [220]

For patients with high programmed death ligand 1 (PD-L1) expression (tumor proportion score [TPS] ≥ 50%), non–squamous cell carcinoma (non-SCC), and performance status (PS) 0 to 1, the ASCO/OH(CCO) guidelines advise that single-agent pembrolizumab should be offered, and that the following regimens may be offered [221] :

  • Pembrolizumab/carboplatin/pemetrexed
  • Atezolizumab/carboplatin/paclitaxel/bevacizumab 
  • Atezolizumab/carboplatin/nab-paclitaxel

For eligible patients with negative or low-positive PD-L1 expression (TPS 0% or 1-49%), non-SCC, and PS 0 to 1, pembrolizumab/carboplatin/pemetrexed should be offered, while atezolizumab/carboplatin/paclitaxel/bevacizumab may be offered. For patients who have contraindications to immunotherapy or who decline it, the guidelines recommend offering standard chemotherapy with two-drug combinations, preferably platinum based.

For patients with high PD-L1 expression (TPS ≥ 50%), SCC, and PS 0 to 1, single-agent pembrolizumab should be offered but pembrolizumab in combination with carboplatin/paclitaxel or nab-paclitaxel may be offered. Single-agent pembrolizumab may also be offered to patients with low-positive PD-L1 expression (TPS 1% to 49%), non-SCC, and PS 0 to 1 who are ineligible for or decline platinum-based doublet therapy.

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