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Updated ASCO Guideline on Stage IV Non–Small Cell Lung Cancer Therapy

An update of the American Society of Clinical Oncology (ASCO) clinical practice guideline, which clarifies the role of immunotherapy for patients with advanced non–small cell lung cancer (NSCLC), was published by Nasser Hanna, MD, Co-Chair of the Expert Panel that developed the guideline update, and colleagues in the Journal of Clinical Oncology. In addition, the update offers new recommendations on the use of targeted therapies for patients with changes in tumor EGFR, ALK, and ROS1 genes. Fourteen randomized controlled clinical trials provided the evidence base for the recommendations.

For first-line treatment of nonsquamous cell carcinoma or squamous cell carcinoma (without positive markers, eg, EGFR/ALK/ROS1), if the patient has high programmed cell death ligand 1 (PD-L1) expression, pembrolizumab should be used alone. If the patient has low PD-L1 expression, clinicians should offer standard chemotherapy.

For second-line treatment of patients who received first-line chemotherapy, without prior immune checkpoint therapy, if the tumor is positive for PD-L1 expression, clinicians should use single-agent nivolumab, pembrolizumab, or atezolizumab; if the tumor is negative or has unknown PD-L1 expression, clinicians should use nivolumab or atezolizumab.

For patients who received a prior first-line immune checkpoint inhibitor, clinicians should offer standard chemotherapy. For patients with a sensitizing EGFR mutation, disease progression after first-line EGFR tyrosine kinase inhibitor therapy, and T790M mutation, osimertinib is recommended; if the tumor lacks the T790M mutation, chemotherapy is recommended.

Patients with ROS1 rearrangement without prior crizotinib may be offered crizotinib. If they previously received crizotinib, they may be offered chemotherapy.