ASCO Living Guideline Updated for Stage IV NSCLC

The American Society of Clinical Oncology (ASCO) indicates that living guidelines are routinely updated guidelines that are created for selected topic areas with swiftly evolving evidence that drives frequent change in clinical practice.

In a recent publication, Dr Navneet Singh, MD, DM, Postgraduate Institute of Medical Education and Research, Chandigarh, India and colleagues provided evidence-based recommendations updating the 2020 ASCO and Ontario Health (Cancer Care Ontario) guideline on systemic therapy for patients with stage IV non–small-cell lung cancer without driver alterations. (Journal of Clinical Oncology doi: 10.1200/JCO.22.00825).

This update is a result of potentially practice-changing evidence published since the last update. In January 2020, ASCO published the last full clinical practice guideline update on systemic therapy for patients with stage IV non-small cell lung cancer (NSCLC) that included those whose cancer did not have driver alterations.

The ASCO updated recommendations on the basis of an ongoing system review of randomized clinical trials from 2018 to 2021.

This guideline update reflects changes in evidence since the previous update, Moreover, five randomized clinical trials provide the evidence base and outcomes of interest include efficacy and safety.

The updated recommendations indicated that in addition to 2020 options for patients with high programmed death ligand-1 (PD-L1) expression (tumor proportion score [TPS] ≥ 50%), nonsquamous cell carcinoma (non-SCC), and performance status (PS) 0-1, clinicians may offer single-agent atezolizumab.

For high PD-L1 expression (TPS ≥ 50%), non-SCC, and PS 0-1, clinicians may offer nivolumab and ipilumumab alone or nivolumab and ipilimumab plus chemotherapy. For negative (0%) and low positive PD-L1 expression (TPS 1%-49%), non-SCC, and PS 0-1, clinicians may recommend nivolumab and ipilimumab alone or nivolumab and ipilimumab plus chemotherapy.

For high PD-L1 expression, SCC, and PS 0-1, clinicians may offer single-agent atezolizumab and with high PD-L1 expression, squamous cell carcinoma (SCC), and PS 0-1, clinicians may offer nivolumab and ipilimumab alone or in combination with two cycles of platinum-based chemotherapy. With negative and low positive PD-L1 expression, SCC, and PS 0-1, clinicians may offer nivolumab and ipilimumab alone or in combination with two cycles of platinum-based chemotherapy.

For non-SCC patients who received an immune checkpoint inhibitor and chemotherapy as first-line therapy, clinicians may offer second-line paclitaxel plus bevacizumab and for non-SCC patients, who received chemotherapy with or without bevacizumab and immune checkpoint inhibitor therapy, clinicians should offer the options of third-line single-agent pemetrexed, docetaxel, or paclitaxel plus bevacizumab.