COMMENTARY

New ASCO Guideline for NSCLC: 'Precision Medicine at Its Best'

Mark G. Kris, MD

Disclosures

June 27, 2017

Hello. This is Mark Kris from Memorial Sloan Kettering, speaking about the release of updated American Society of Clinical Oncology (ASCO) guidelines[1] for the treatment of completely resected lung adenocarcinomas and squamous cell carcinomas. A number of experts from across North America reviewed the literature on adjuvant therapy of lung cancers to update and make new recommendations. I had the opportunity to serve as co-chair of that committee with Laurie Gaspar from the University of Colorado.

There has been no pivotal trial leading to introduction of a new therapy.

The standard of care for stages IB through IIIA completely resected lung adenocarcinomas and squamous carcinomas is to give cisplatin-based chemotherapy.

For radiation, there is no new information to show that it would be helpful for stage I or stage II lung cancer. However, there are compelling data from a number of different sources finding that radiation can be helpful in the treatment of patients with stage IIIA N2 disease. The guideline addresses this.

The guideline also reports new data showing that the benefit to patients with stage IB lung cancers is present with cisplatin-based chemotherapy regardless of the size. I would be very careful about being hard-nosed about centimeter number—it has made its way into medical thinking. That is not part of official staging. According to data from a large national database in the United States, there is benefit regardless of tumor size (ie, ≥ 2 cm).

I want to bring to your attention two key things in this guideline. Clearly, the decision to give chemotherapy to a stage IB patient is complicated, based on the literature, size of tumor, stage, and individual patient characteristics. The guideline recommends that there be a multimodality discussion about the benefits of adjuvant chemotherapy. I urge you to consider that in your practice and to make it part of your care. When you have a patient with locally advanced lung cancer, which sadly has a very poor 5-year survival, address the benefits and risks of adjuvant cisplatin-based chemotherapy in every patient with stage IB disease.

For patients with stage IIIA N2 disease, the same can be said for radiation. We do not have a definitive trial saying that every patient should be radiated. The guideline says it is not recommended for routine use. However, the guideline does state that there is a strong potential for benefit. It is good medical care that, in every patient with completely resected stage IIIA N2 disease after completion of cisplatin-based chemotherapy, a multimodality discussion occur with a radiation oncologist on whether that patient could benefit from radiation.

In the article, you will find a very nice table that builds off of the Lung Adjuvant Cisplatin Evaluation (LACE) meta-analysis that uses the adjuvant online formula. It shows how many patients are cured by surgery alone and how many additional patients can be cured by our adjuvant strategies. It is very useful for explaining the benefits of adjuvant therapy to patients stage by stage. I urge you to use that table to help you clarify your own thinking. It would be a useful graphic for selected patients.

ASCO has again updated the adjuvant guidelines. The theme here, and going forward in all of thoracic oncology, is multimodality therapy. I look forward to the day when no single case of lung cancer has not had a multimodality evaluation. These guidelines are one more step closer to that. I urge you to think multimodality in all aspects of care for patients with thoracic malignancies. Obviously, multimodality care is not right for every patient, but it should be considered in every patient, and individual decisions should be made. Hopefully you will find these guidelines useful.

This is precision medicine at its best and what we have all aspired to all along. Now that we have more tools, it is even more important to put our best minds together for each and every patient.

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