Systemic Therapy for Stage IV Non-Small-Cell Lung Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. Systemic Therapy for Stage IV Non-Small-Cell Lung Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. Treatment of stage III non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Image-Guided Hypofractionated Small Volume Radiotherapy of Non-Small Cell Lung Cancer – Feasibility and Clinical Outcome Impact of new chemotherapeutic and targeted agents on survival in stage IV non-small cell lung cancer. Stereotactic body radiation therapy for early-stage non-small cell lung cancer: Executive Summary of an ASTRO Evidence-Based Guideline. Treatment of stage II non-small cell lung cancer. Clinical Staging of Stage I Non-Small Cell Lung Cancer in the Netherlands-Need for Improvement in an Era With Expanding Nonsurgical Treatment Options: Data From the Dutch Lung Surgery Audit. Systemic therapy in the curative treatment of head-and-neck squamous cell cancer: Cancer Care Ontario clinical practice guideline. Prognostic factors for survival of stage I nonsmall cell lung cancer patients American Society of Clinical Oncology Clinical Practice Guideline update on chemotherapy for stage IV non-small-cell lung cancer. 7‐year follow‐up after stereotactic ablative radiotherapy for patients with stage I non–small cell lung cancer: Results of a phase 2 clinical trial Poor correspondence between clinical and pathologic staging in stage 1 non-small cell lung cancer: results from CALGB 9761, a prospective trial. An Evidence-Based Approach to the Use of Predictive Biomarkers in the Treatment of Non- Small Cell Lung Cancer (NSCLC) Outcomes of Pulmonary Rehabilitation After Treatment for Non-Small Cell Lung Cancer Stages I to IIIa: AN OBSERVATIONAL STUDY Survival of patients with true pathologic stage I non-small cell lung cancer. Eligibility of patients with advanced non-small cell lung cancer for phase III chemotherapy trials
Purpose Provide evidence -based recommendations updating the 2015 ASCO guideline on systemic therapy for patients with stage IV non-small-cell lung cancer ( NSCLC ) . Methods The ASCO NSCLC Expert Panel made recommendations based on a systematic review of r and omized controlled trials from February 2014 to December 2016 plus the Cancer Care Ontario Program in Evidence -Based Care 's up date of a previous ASCO search . Results This guideline up date reflects changes in evidence since the previous guideline up date . Fourteen r and omized controlled trials provide the evidence base ; earlier phase trials also informed recommendation development . Recommendations New or revised recommendations include the following . Regarding first-line treatment for patients with non-squamous cell carcinoma or squamous cell carcinoma ( without positive markers , eg , EGFR/ALK /ROS1 ) , if the patient has high programmed death lig and 1 ( PD-L1 ) expression , pembrolizumab should be used alone ; if the patient has low PD-L1 expression , clinicians should offer st and ard chemotherapy . All other clinical scenarios follow 2015 recommendations . Regarding second-line treatment in patients who received first-line chemotherapy  , without prior immune checkpoint therapy , if NSCLC tumor is positive for PD-L1 expression , clinicians should use single-agent nivolumab , pembrolizumab , or atezolizumab ; if tumor has negative or unknown PD-L1 expression , clinicians should use nivolumab or atezolizumab . All immune checkpoint therapy is recommended alone plus in the absence of contraindications . For patients who received a prior first-line immune checkpoint inhibitor , clinicians should offer st and ard chemotherapy . For patients who can not receive immune checkpoint inhibitor after chemotherapy , docetaxel is recommended ; in patients with nonsquamous NSCLC , pemetrexed is recommended . In patients with a sensitizing EGFR mutation , disease progression after first-line epidermal growth factor receptor tyrosine kinase inhibitor therapy , and T790 M mutation , osimertinib is recommended ; if NSCLC lacks the T790 M mutation , then chemotherapy is recommended . Patients with ROS1 gene rearrangement without prior crizotinib may be offered crizotinib , or if they previously received crizotinib , they may be offered chemotherapy Purpose To provide evidence -based recommendations to up date the American Society of Clinical Oncology guideline on systemic therapy for stage IV non – small-cell lung cancer ( NSCLC ) . Methods An Up date Committee of the American Society of Clinical Oncology NSCLC Expert Panel based recommendations on a systematic review of r and omized controlled trials from January 2007 to February 2014 . Results This guideline up date reflects changes in evidence since the previous guideline . Recommendations There is no cure for patients with stage IV NSCLC . For patients with performance status ( PS ) 0 to 1 ( and appropriate patient cases with PS 2 ) and without an EGFR-sensitizing mutation or ALK gene rearrangement , combination cytotoxic chemotherapy is recommended , guided by histology , with early concurrent palliative care . Recommendations for patients in the first-line setting include platinum-doublet therapy for those with PS 0 to 1 ( bevacizumab may be added to carboplatin plus paclitaxel if no contraindications ) ; combination or single-agent chemotherapy or palliative care alone for those with PS 2 ; afatinib , erlotinib , or gefitinib for those with sensitizing EGFR mutations ; crizotinib for those with ALK or ROS1 gene rearrangement ; and following first-line recommendations or using platinum plus etoposide for those with large-cell neuroendocrine carcinoma . Maintenance therapy includes pemetrexed continuation for patients with stable disease or response to first-line pemetrexed-containing regimens , alternative chemotherapy , or a chemotherapy break . In the second-line setting , recommendations include docetaxel , erlotinib , gefitinib , or pemetrexed for patients with nonsquamous cell carcinoma ; docetaxel , erlotinib , or gefitinib for those with squamous cell carcinoma ; and chemotherapy or ceritinib for those with ALK rearrangement who experience progression after crizotinib . In the third-line setting , for patients who have not received erlotinib or gefitinib , treatment with erlotinib is recommended . There are insufficient data to recommend routine third-line cytotoxic therapy . Decisions regarding systemic therapy should not be made based on age alone . Additional information can be found at http://www.asco.org/ guidelines /nsclc and http://www.asco.org/ guidelines wiki . J Clin Oncol 33:3488 - 3515 . © 2015 by American Society of Clinical OBJECTIVES Stage III non-small cell lung cancer ( NSCLC ) describes a heterogeneous population with disease presentation ranging from apparently resectable tumors with occult microscopic nodal metastases to unresectable , bulky nodal disease . This review up date s the published clinical trials since the last American College of Chest Physicians guidelines to make treatment recommendations for this controversial subset of patients . METHODS Systematic search es were conducted through MEDLINE , Embase , and the Cochrane Data base for Systematic Review up to December 2011 , focusing primarily on r and omized trials , selected meta-analyses , practice guidelines , and review s. RESULTS For individuals with stage IIIA or IIIB disease , good performance scores , and minimal weight loss , treatment with combined chemoradiotherapy results in better survival than radiotherapy alone . Consolidation chemotherapy or targeted therapy following definitive chemoradiation for stage IIIA is not supported . Neoadjuvant therapy followed by surgery is neither clearly better nor clearly worse than definitive chemoradiation . Most of the arguments made regarding patient selection for neoadjuvant therapy and surgical resection provide evidence for better prognosis but not for a beneficial impact of this treatment strategy ; however , weak comparative data suggest a possible role if only lobectomy is needed in a center with a low perioperative mortality rate . The evidence supports routine platinum-based adjuvant chemotherapy following complete resection of stage IIIA lung cancer encountered unexpectedly at surgery . Postoperative radiotherapy  improves local control without improving survival . CONCLUSIONS Multimodality therapy is preferable in most subsets of patients with stage III lung cancer . Variability in the patients included in r and omized trials limits the ability to combine results across studies and thus limits the strength of recommendations in many scenarios . Future trials are needed to investigate the roles of individualized chemotherapy , surgery in particular cohorts or setting s , prophylactic cranial radiation , and adaptive radiation Purpose : Local hypofractionated stereotactic radiation treatment ( hfSRT ) of early stage non-small cell lung cancer ( NSCLC ) represents a highly effective treatment alternative in medically inoperable patients . Method : Between June 2007 and December 2010 , 65 patients with NSCLC were treated with image-guided hypofractionated radiotherapy . The Union Internationale Contre le Cancer ( UICC ) stage distribution was : IA , n = 19 ; IB , n = 15 ; IIB , n = 5 ; IIIA , n = 10 ; IIIB , n = 6 ; and IV , n = 10 . The fractionation schedule used was 3 × 12.5 Gy ( n = 36 ) prescribed to the encompassing 67 % isodose line for peripheral primary tumours , and 8 × 6 Gy ( n = 26 ) or 8 × 5 Gy ( n = 3 ) prescribed to the encompassing 80 % isodose line for central ly located tumours . Results : Mean follow-up was 13.8 months ( range 1–41 months ) . Until now 6 patients developed a local recurrence , 2 of them in combination with mediastinal lymph node failure . The 1-year actuarial local control rate was 93 % and overall survival 79 % . Pneumonitis was seen in 14 patients ( 21.5 % ) ( Common Terminology Criteria for Adverse Events ( CTCAE ) grade I : n = 12 , and II : n = 2 ) after a median time period of 9.5 months . No patient developed pneumonitis of CTCAE grade III or higher . Conclusion : Image-guided hfSRT  is effective and feasible in patients with non-operable NSCLC , even in higher stages , whenever local control is crucial and there are contraindications against systemic therapy e18015 Background : Significant advances in the systemic management of metastatic non-small cell lung cancer ( NSCLC ) have occurred over the past decade , with options now including multiple lines of chemotherapy , EGFR inhibitors , and anti-angiogenic agents . Improvements in overall survival have been demonstrated in r and omized controlled trials comparing these newer agents to best supportive care ( BSC ) or st and ard therapy . This study examined uptake of these therapies in general practice and their impact on survival . METHODS This retrospective cohort study compared demographic , treatment and survival data among 987 patients diagnosed with stage IV NSCLC at two institutions in 1998 , 2003 , and 2008 . Cohorts were selected based on intervals when doublet chemotherapy , second line chemotherapy , and targeted agents were incorporated into the st and ard treatment regimen . RESULTS The proportion of patients receiving systemic therapy increased over time ( 20 % in 1998 , 42 % in 2008 ) . Treated patients diagnosed in 2008 were more likely to receive ≥2 lines of systemic therapy ( 60 % vs. 7 % in 1998 ) . Overall survival improved significantly across cohorts ( P < 0.001 ) , with 2 year survival rates of 0.3 % in 1998 , 4 % in 2003 , and 15 % in 2008 . After controlling for other variables , risk of death was diminished by 55 % in patients receiving 1 line of systemic therapy and 72 % in those receiving ≥2 lines , compared with BSC alone . Elderly patients ( age ≥70 years ) were also more likely to receive systemic therapy over time , with improved overall survival ( P < 0.001 ) . CONCLUSIONS Over the past decade , there has been increased use of systemic therapy in stage IV NSCLC patients , including the elderly . This has been associated with significantly improved overall survival PURPOSE This guideline presents evidence -based recommendations for stereotactic body radiation therapy ( SBRT ) in challenging clinical scenarios in early-stage non-small cell lung cancer ( NSCLC ) . METHODS AND MATERIAL S The American Society for Radiation Oncology convened a task force to perform a systematic literature review on 4 key questions addressing : ( 1 ) application of SBRT to operable patients ; ( 2 ) appropriate use of SBRT in tumors that are central ly located , large , multifocal , or unbiopsied ; ( 3 ) individual tailoring of SBRT in " high-risk " clinical scenarios ; and ( 4 ) SBRT as salvage therapy after recurrence . Guideline recommendations were created using a predefined consensus-building methodology supported by American Society for Radiation Oncology-approved tools for grading evidence quality and recommendation strength . RESULTS Although few r and omized trials have been completed for SBRT , strong consensus recommendations based on extensive , consistent publications were generated for several questions , including recommendations for fractionation for central tumors and surgery versus SBRT in st and ard-risk medically operable patients with early-stage NSCLC . Lower quality evidence led to conditional recommendations on use of SBRT for tumors > 5 cm , patients with prior pneumonectomy , T3 tumors with chest wall invasion , synchronous multiple primary lung cancer , and as a salvage therapy after prior radiation therapy . These areas of moderate- and low- quality evidence highlight the importance of clinical trial enrollment as well as the role of prospect i ve data registries . CONCLUSIONS SBRT has an important role to play in treating early-stage NSCLC , particularly for medically inoperable patients with limited other treatment options . Shared decision-making with patients should be performed in all cases to ensure the patient underst and s the risks related to SBRT , the side effects , and the alternative treatments available Based on clinical assessment alone , patients with stage II non-small cell lung cancer ( NSCLC ) comprise only 5 % of all patients with NSCLC . In addition , patients with stage II NSCLC represent a heterogeneous group , since stage II consists of patients with T1 - 2N1 or T3N0 tumors . By definition , patients with tumor invading the chest wall apex , mediastinum , diaphragm , or even the mainstem bronchus may all have T3 tumors . The extent of the data available regarding treatment of each of these different groups is therefore limited . The quality of the data is limited as well , because information often comes from small series of patients . Studies of adjuvant therapy after complete resection of stage II NSCLC are an important exception to this generalization , since data from large , r and omized studies of adjuvant radiation therapy , chemotherapy , or a combination of the two are available for analysis . Superior sulcus tumors are discussed elsewhere in these guidelines BACKGROUND The clinical stage of non-small cell lung cancer ( NSCLC ) determines the initial treatment , whereas the pathologic stage best determines prognosis and the need for adjuvant treatment . In an era in which stereotactic ablative radiotherapy ( SABR ) has become an alternative modality to surgical intervention , clinical staging is even more important , because pathologic staging is omitted in the case of SABR . The objective of this study was to determine the concordance between clinical and pathologic stage in routine clinical practice for patients with early-stage NSCLC . METHODS Prospect i ve data were derived from the Dutch Lung Surgery Audit ( DLSA ) in 2013 and 2014 . Patients with clinical stage I NSCLC who underwent surgical resection and had a positron emission tomography-computed tomography ( PET-CT ) scan in their clinical workup were selected .  Clinical and pathologic TNM ( cTNM and pTNM ) stages were compared . RESULTS From a total of 1,790 patients with clinical stage I , 1,555 ( 87 % ) patients were included in this analysis . Concordance between cTNM and pTNM was 59.9 % . Of the patients with clinical stage I , 22.6 % were upstaged to pathologic stage II or higher . In total , 14.9 % of all patients with clinical stage I had nodal metastases , and 5.5 % of all patients had unforeseen N2 disease . In patients with clinical stage T2a tumors , 21.3 % had nodal metastases , 14.5 % being N1 and 6.7 % being N2 disease . CONCLUSIONS Concordance between clinical and pathologic stage is 59.9 % . In patients with clinical stage I NSCLC , 22.6 % were upstaged to pathologic stage II or higher , which is an indication for adjuvant chemotherapy . Improvement in accuracy of staging is thus needed , particularly for these patients OBJECTIVE The aim of the present work was to make recommendations about the use of systemically administered drugs in combination or in sequence with radiation ( rt ) or surgery , or both , for cure or organ preservation , or both , in patients with locally advanced nonmetastatic ( stages iii-ivb ) squamous cell carcinoma of the head and neck ( lascchn ) . METHODS The Meta- analysis of Chemotherapy in Head and Neck Cancer ( mach-nc ) reports have , de facto , guided practice since 2000 , and so we search ed the literature for systematic review s published from January 2000 to February 2015 in reference to five research questions . A search was also conducted up to February 2015 for r and omized trials ( rcts ) not included in the meta-analyses . Recommendations were constructed using the Cancer Care Ontario Program in Evidence -Based Care practice guidelines development cycle . RESULTS In addition to up date d mach-nc reports , five additional meta-analyses and thirty rcts were identified . Five recommendations for lascchn treatment were generated based on those data . Concurrent chemoradiation ( ccrt ) is recommended to maximize the chance of cure in patients less than 71 years of age when rt is used as definitive treatment . The same recommendation also applies to patients with resected lascchn considered to be at high risk for locoregional recurrence . For lascchn patients who are c and i date s for organ preservation strategies and would otherwise require total laryngectomy , either ccrt or induction chemotherapy , followed by rt or surgery based on tumour response is recommended . The addition of cetuximab to intensified rt ( concomitant boost or hyperfractionated schedule ) is an alternative to ccrt . Routine use of induction chemotherapy to improve overall survival is not recommended . CONCLUSIONS We were able to use high-level evidence from patients receiving rt as definitive or postoperative treatment to generate recommendations for the use of systemic therapy in the treatment of lascchn . A limitation is a lack of stratification for human papillomavirus-related cancers of the oropharynx . One rct provided evidence for the use of cetuximab as an alternative to chemotherapy in the definitive rt setting . Concurrent chemoradiation provides one strategy for larynx preservation , but the best strategy is unclear . Use of induction chemotherapy does not improve overall survival , and its use should be limited to patients requiring immediate tumour downsizing before local therapy Platinum‐based adjuvant chemotherapy in r and omized trials has failed to provide a survival benefit in patients with resected stage I nonsmall cell lung cancer ( NSCLC ) . Using data from the California Cancer Registry ( CCR ) , we explored factors that had detrimental effects on survival in patients with stage I NSCLC to identify a subset of patients at high risk for disease recurrence and subsequent mortality The purpose of this article is to provide up date d recommendations for the treatment of patients with stage IV non-small-cell lung cancer . A literature search identified relevant r and omized trials published since 2002 . The scope of the guideline was narrowed to chemotherapy and biologic therapy . An Up date Committee review ed the literature and made up date d recommendations . One hundred sixty-two publications met the inclusion criteria . Recommendations were based on treatment strategies that improve overall survival . Treatments that improve only progression-free survival prompted scrutiny of toxicity and quality of life . For first-line therapy in patients with performance status of 0 or 1 , a platinum-based two-drug combination of cytotoxic drugs is recommended . Nonplatinum cytotoxic doublets are acceptable for patients with contraindications to platinum therapy . For patients with performance status of 2 , a single cytotoxic drug is sufficient . Stop first-line cytotoxic chemotherapy at disease progression or after four cycles in patients who are not responding to treatment . Stop two-drug cytotoxic chemotherapy at six cycles even in patients who are responding to therapy . The first-line use of gefitinib may be recommended for patients with known epidermal growth factor receptor ( EGFR ) mutation ; for negative or unknown EGFR mutation status , cytotoxic chemotherapy is preferred . Bevacizumab is recommended with carboplatin-paclitaxel , except for patients with certain clinical characteristics . Cetuximab is recommended with cisplatin-vinorelbine for patients with EGFR-positive tumors by immunohistochemistry . Docetaxel , erlotinib , gefitinib , or pemetrexed is recommended as second-line therapy . Erlotinib is recommended as third-line therapy for patients who have not received prior erlotinib or gefitinib . Data are insufficient to recommend the routine third-line use of cytotoxic drugs . Data are insufficient to recommend routine use of molecular markers to select chemotherapy The authors evaluated the efficacy , patterns of failure , and toxicity of stereotactic ablative radiotherapy ( SABR ) for patients with medically inoperable , clinical stage I non – small cell lung cancer ( NSCLC ) in a prospect i ve clinical trial with 7 years of follow‐up . Clinical staging was performed according to the seventh edition of the American Joint Committee on Cancer TNM staging system PURPOSE A major problem with the staging system for non-small cell lung cancer ( NSCLC ) is clinical underestimation of the extent of disease . Many patients with clinical stage 1 disease do not retain that design ation following surgical resection . Herein , we present data from Cancer and Leukemia Group B ( CALGB ) protocol 9761 evaluating the correspondence between clinical and pathologic analysis in early stage NSCLC . METHODS Five hundred and two patients with suspected or biopsy-proven NSCLC classified as clinical stage 1 ( T1 - 2 , N0 ) by computed tomography ( CT ) scan or cervical mediastinoscopy were prospect ively enrolled in CALGB 9761 . The purpose of CALGB 9761 was to prospect ively evaluate molecular markers of micrometastatic disease in stage 1 NSCLC . Enrollment occurred at 11 selected institutions within the CALGB . Patients with clinical ly suspected resectable early stage lung cancer were eligible for enrollment if they had no evidence of mediastinal or hilar adenopathy on CT scan or if they had CT evidence of potential N2 or N3 disease ( lymph node > or = 1.0 cm ) but with negative mediastinoscopy . No prior chemotherapy  or  radiotherapy  was permitted . RESULTS Of the 502 patients felt to have clinical stage 1 NSCLC enrolled in CALGB 9761 , 489 underwent resection with complete surgical staging and routine histopathologic analysis . From these 489 patients , only 422 ( 86.3 % ) turned out to have pathologically documented NSCLC . Of these 422 patients , 302 ( 71.6 % ) had pathologic stage 1 disease ( 173 stage 1A and 129 stage 1B ) . Despite clinical assessment of stage 1 disease , 59 ( 14 % ) patients had pathologic stage 2 disease , 57 ( 13.5 % ) had stage 3 disease , and four ( 0.9 % ) patients had stage 4 disease . Of the patients undergoing resection for clinical stage 1 NSCLC , 65 patients did not have NSCLC ( 44 had benign disease and 21 had malignancies other than NSCLC ) and two additional patients had dual synchronous primary NSCLC tumors and were not eligible for the study . Overall , only 61.7 % ( 302 of 489 ) of patients with suspected stage 1 NSCLC disease retained that stage and diagnosis after complete surgical staging , while 38.3 % had an inaccurate pre-operative clinical stage or diagnosis . CONCLUSIONS The results from this prospect i ve trial demonstrate the poor predictive value of current clinical staging techniques in early stage NSCLC . These findings will serve as a benchmark for comparison of future clinical imaging modalities and other tests evaluating early stage NSCLC Recent advances in the treatment of non-small cell lung cancer ( NSCLC ) have led to improvements in patient survival and quality of life . It is unclear whether molecular abnormalities associated with NSCLC cell survival , growth and proliferation are useful in predicting treatment benefit . We conducted a systematic review to establish which biomarkers contribute meaningfully to the management of NSCLC . A team of research ers search ed PubMed and conference proceedings ( ASCO , ESMO , IASLC , USCAP ) using MESH terms for NSCLC and r and omized trials ( RCT ) , plus keywords for variables of interest . Evidence from multiple RCTs confirmed that histologic subtype is prognostic for survival and predictive of treatment efficacy and /or toxicity in NSCLC . Likewise , activating mutations of the epidermal growth factor receptor ( EGFR ) are associated with benefit from EGFR tyrosine kinase inhibitors in patients with advanced non-squamous NSCLC and should be assessed routinely . No biomarkers to date reliably predict response to anti-Vascular Endothelial Growth Factor ( VEGF ) therapies . There are inconsistent data on the role of ERCC1 , BRCA , Beta tubulin III , RRM1 , K-RAS , or TP-53 in treatment decisions . These tests should not be routinely used in selecting treatment at this time , whereas EML4/ALK translocations predict responses to specific targeted agents , the optimal assessment of this molecular abnormality has yet to be established . Personalized care of patients with NSCLC based on biomarkers is increasingly important to both clinical practice and research PURPOSE : Although rehabilitation after treatment for non-small cell lung cancer ( NSCLC ) was found to have a beneficial effect on exercise capacity in a number of studies , insight into its effect on quality of life ( QoL ) and fatigue is limited . The aim of this study was to examine the outcome of pulmonary rehabilitation ( PR ) regarding fatigue , QoL , and exercise capacity in adult patients curatively treated for NSCLC stages I to IIIa . METHODS : Study data were prospect ively and routinely gathered in daily practice in patients taking part in an outpatient PR program after treatment for NSCLC stages I to IIIa . PR consisted of 12 weeks of supervised exercises 3 times a week , supplemented with scheduled visits with members of a multidisciplinary team . Data were gathered at initial assessment and discharge . Outcomes included fatigue ( the Functional Assessment of Cancer Therapy-Fatigue and the fatigue domain of the Chronic Respiratory Disease Question naire ) ; QoL ( total CRQ score ) , Functional Assessment of Cancer Therapy-Lung , and the Short Form 36 ; and exercise capacity ( cardiopulmonary exercise testing ) . RESULTS : Fifty patients started the program out of the 70 patients referred to PR and 43 ( 86 % ) completed the program . Significant ( P ⩽ .01 ) and clinical ly relevant improvements were observed for all outcome measures . CONCLUSIONS : Rehabilitation after treatment for NSCLC stages I to IIIa showed promising improvements regarding patient fatigue , QoL , and exercise capacity . PR should be considered for patients after treatment for NSCLC stages I to IIIa BACKGROUND Many patients with resected , pathologic (p)stage I non-small cell lung cancer ( NSCLC ) are not adequately staged preoperatively or intraoperatively . Reported 5-year survival is about 65 % . Recently , nonsurgical techniques are being offered to these patients . METHODS A prospect i ve data base was retrospectively review ed . All patients had an integrated positron-emission tomography/computed tomography ( CT ) and CT scan , an R0 pulmonary resection with lung palpation , and complete thoracic lymphadenectomy .  RESULTS From August 2002 until July 2008 , 2171 patients presented with presumed , resectable NSCLC . Of these , 721 were clinical ly (c)staged I , and 1450 were (c)staged II , III , or IV . Of the 721 (c)stage I , 405 ( 56 % ) had (p)stage I disease ; 101 ( 14 % ) were clinical ly over-staged ( benign nodules ) . Of those with NSCLC , 32 % were clinical ly under-staged ( stage II or higher on path ) . The 5-year Kaplan-Meier survival rates were 80 % for (p)stage IA , 72 % for (p)stage IB ( p = 0.026 ) , and 87 % for the 721 with (c)stage I disease . The median-follow up was 3.8 years . CONCLUSIONS When patients with NCSLC are accurately staged preoperatively and undergo complete thoracic lymphadenectomy , the 5-year survival is 80 % for (p)stage IA tumors and 87 % for (c)stage I disease . About 32 % of patients are under-staged ( most commonly from nonimaged N2 disease ) despite the liberal application of all of the techniques that assess mediastinal lymph nodes preoperatively . Thus surgical intervention offers improved staging with resection of unsuspected nodal or parenchymal disease . If stereotactic radiation and radiofrequency ablation are considered for patients with clinical ly staged I NSCLC , these results should be considered Background Evidence that chemotherapy improves survival and quality of life in patients with stage IIIB & IV non small cell lung cancer ( NSCLC ) is based on large r and omized controlled trials . The purpose of this study was to determine eligibility of patients with advanced NSCLC for major chemotherapy trials . Methods Physicians treating stage IIIB/IV NSCLC at Sydney Cancer Centre assessed patient eligibility for the E1594 , SWOG9509 and TAX326 trials for patients presenting from October 2001 to December 2002 . A review of the centre 's registry was used to obtain missing data . Results 199 patients with advanced NSCLC were registered during the 14-month period . Characteristics of 100 patients were defined prospect ively , 85 retrospectively : 77 % males , median age 68 ( range 32–88 ) , 64 % stage IV disease . Only 35 % met trial eligibility for E1594 and 28 % for SWOG9509 and TAX326 . Common reasons for in eligibility were : co-morbidities 75(40 % ) ; ECOG Performance Status ≥2 72(39 % ) ; symptomatic brain metastasis 15(8 % ) ; and previous cancers 21(11 % ) . Many patients were ineligible by more than one criterion . Conclusion The majority of patients with advanced NSCLC were ineligible for the large chemotherapy trials . The applicability of trial results to advanced lung cancer population s may be limited . Future trials should be conducted in a more representative population
In the third-line setting , for patients who have not received erlotinib or gefitinib , treatment with erlotinib is recommended .
There are insufficient data to recommend routine third-line cytotoxic therapy .
Purpose To provide evidence -based recommendations to up date the American Society of Clinical Oncology guideline on systemic therapy for stage IV non – small-cell lung cancer ( NSCLC ) .
Results This guideline up date reflects changes in evidence since the previous guideline .