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 This is an original JCO publication from 2015. Please visit the JCO website to access the full article.


Postoperative Radiation Therapy for Endometrial Cancer: American Society of Clinical Oncology Clinical Practice Guideline Endorsement of the American Society for Radiation Oncology Evidence-Based Guideline


 

 Authors

Charles M. Rudin, Nofisat Ismaila, Christine L. Hann, Narinder Malhotra, Benjamin Movsas, Kim Norris, M. Catherine Pietanza, Suresh S. Ramalingam, Andrew T. Turrisi III, and Giuseppe Giaccone

THE BOTTOM LINE

ASCO Endorses the ACCP Clinical Practice Guideline on the Treatment of Small-Cell Lung Cancer, With Minor Qualifying Statements

Guideline Questions
1. In patients with small-cell lung cancer (SCLC), what is the ability of positron emission tomography (PET) imaging to determine the stage of cancer?

2. In patients with limited-stage (LS) SCLC, how do the parameters of thoracic radiotherapy (TRT) affect survival?

3. In patients with extensive-stage (ES) SCLC, what is the survival after treatment with chemotherapy, including novel and targeted agents?

4. In elderly patients with SCLC, what are survival and toxicity after treatment with chemotherapy or radiation therapy?

Target Population
Patients with SCLC


Target Audience
Primary care providers, oncologists, radiologists, pathologists, and other health providers


Methods
An American Society of Clinical Oncology (ASCO) Endorsement Panel was convened to consider endorsing the American College of Chest Physicians (ACCP) guideline recommendations on the treatment of SCLC, which were based on a systematic review of the medical literature. The ASCO Endorsement Panel considered the methodology employed in the ACCP guideline using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) review instrument. The ASCO Endorsement Panel carefully reviewed the ACCP guideline content to determine appropriateness for ASCO endorsement.


ASCO Key Recommendations for Treatment of SCLC
ASCO qualifying statements appear in bold italics (with remarks shown in italics). Data Supplement 1 provides a reprint of all the ACCP recommendations.

● In patients with SCLC (proven or suspected), a staging evaluation is recommended consisting of a medical history and physical examination, CBC and comprehensive chemistry panel with renal and hepatic function tests, CT [computed tomography] of the chest and abdomen with intravenous contrast or CT scan of the chest extending through the liver and adrenal glands, MRI [magnetic resonance imaging] or CT of the brain, and bone scan (grade 1B). If PET is obtained, then bone scan may be omitted. CBC should include differential.

● In patients with clinically LS SCLC, PET imaging is suggested (grade 2C). Remark: If PET is obtained, then bone scan may be omitted. PET scan use is also applicable to ES SCLC.

● In patients with SCLC, it is recommended that both the Veterans’ Administration system (LS v ES) and the American Joint Committee on Cancer/International Union Against Cancer seventh edition system (TNM) should be used to classify the tumor stage (grade 1B).

● In patients with clinical stage I SCLC, who are being considered for curative intent surgical resection, invasive mediastinal staging and extrathoracic imaging (head MRI/CT and PET or abdominal CT plus bone scan) are recommended (grade 1B).

● In patients with clinical stage I SCLC, after a thorough evaluation for distant metastases and invasive mediastinal stage evaluation, surgical resection is suggested over nonsurgical treatment (grade 2C).

● In patients with stage I SCLC who have undergone curative-intent surgical resection, platinum-based adjuvant chemotherapy is recommended (grade 1C).

● In patients with LS SCLC, early chemoradiotherapy, with accelerated hyperfractionated radiation therapy (twice-daily treatment) concurrently with platinum-based chemotherapy, is recommended (grade 1B). Comparison of accelerated hyperfractionated radiotherapy with an extended course of daily radiation therapy at standard fractionation is currently being investigated.

● In patients with LS or ES SCLC who achieve a complete or partial response to initial therapy, prophylactic cranial irradiation [PCI] is recommended (grade 1B). Remark: The regimen of 25 Gy in 10 daily fractions has the greatest supporting data for safety and efficacy. The panel notes that a recent Japanese study failed to demonstrate survival advantage with PCI in patients with ES SCLC. On publication of the mature data from this study, the recommendation for PCI in ES SCLC might be subject to revision.

● In patients with ES SCLC who have completed chemotherapy and achieved a complete response outside the chest and complete or partial response in the chest, a course of consolidative TRT is suggested (grade 2C). Further evaluation of this question is required before a treatment recommendation can be made.

● In patients with either LS or ES SCLC, four to six cycles of platinum-based chemotherapy with either cisplatin or carboplatin plus either etoposide or irinotecan are recommended over other chemotherapy regimens (grade 1A). Clinical trials in the United States and Europe have not demonstrated a benefit for the irinotecan regimen over that based on etoposide. In LS disease, four cycles is preferred.

● In patients with relapsed or refractory SCLC, the administration of second-line, single-agent chemotherapy is recommended (grade 1B). Remark: Reinitiation of the previously administered first-line chemotherapy regimen is recommended in patients who experience relapse 6 months from completion of initial chemotherapy. Enrollment onto a clinical trial is encouraged. Single-agent topotecan has US Food and Drug Administration approval in this context.

● In elderly patients with LS SCLC and good performance status (PS; Eastern Cooperative Oncology Group [ECOG] 0 to 2), treatment with platinum-based chemotherapy plus TRT is suggested, with close attention to management of treatmentrelated toxicity (grade 2B).

● In elderly patients with ES SCLC and good PS (ECOG 0 to 2), treatment with carboplatin-based chemotherapy is suggested (grade 2A).

● In elderly patients with SCLC and poor PS, treatment with chemotherapy is suggested if the poor PS is due to SCLC (grade 2C).


Additional Resources
More information, including a Data Supplement, a Methodology Supplement, slide sets, and clinical tools and resources, is available at http://www.asco.org/endorsements/sclc and http://www.asco.org/guidelineswiki. Patient information is available at http://www.cancer.net

A link to the ACCP guideline recommendations on treatment of SCLC can be found at http://www.chestnet.org/.


ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care and that all patients should have the opportunity to participate.

SUMMARY OF RECOMMENDATIONS

Treatment of Small Cell Lung Cancer: American Society of Clinical Oncology Endorsement of The American College of Chest Physicians (ACCP) Guideline
ASCO Guideline QuestionACCP Recommendation with ASCO Qualifying Statements in Bold Italics
Staging of SCLC
In patients with SCLC, what is the ability of PET imaging to determine the stage of cancer?In patients with SCLC (proven or suspected), a staging evaluation is recommended consisting of a medical history and physical examination, CBC and comprehensive chemistry panel with renal and hepatic function tests, CT of the chest and abdomen with intravenous contrast or CT scan of the chest extending through the liver and adrenal glands, MRI or CT of the brain, and bone scan (Grade 1B). If PET is obtained, then bone scan may be omitted. CBC should include differential.
In patients with clinically limited-stage (LS)-SCLC, PET imaging is suggested (Grade 2C). Remark: If PET is obtained, then bone scan may be omitted. PET scan use is also applicable to ES-SCLC
 In patients with SCLC, it is recommended that both the Veterans Administration system (LS vs extensive stage [ES]) and the American Joint Committee on Cancer/International Union Against Cancer seventh edition system (TNM) should be used to classify the tumor stage (Grade 1B).
Role of Surgery
 In patients with clinical stage I SCLC, who are being considered for curative intent surgical resection, invasive mediastinal staging and extrathoracic imaging (head MRI/CT and PET or abdominal CT plus bone scan) is recommended (Grade 1B).
 In patients with clinical stage I SCLC after a thorough evaluation for distant metastases and invasive mediastinal stage evaluation, surgical resection is suggested over non-surgical treatment (Grade 2C).
 In patients with stage I SCLC who have undergone curative-intent surgical resection, platinum-based adjuvant chemotherapy is recommended (Grade 1C).
Use of Radiation Therapy for SCLC
In patients with LS-SCLC, how do the parameters of thoracic radiotherapy (TRT) affect survival?In patients with LS-SCLC, early chemoradiotherapy, with accelerated hyper-fractionated radiation therapy (twice-daily treatment) concurrently with platinum-based chemotherapy, is recommended (Grade 1B). Comparison of accelerated hyperfractionated radiotherapy with an extended course of daily radiation at standard fractionation is currently being investigated
In patients with ES-SCLC, what is the survival after treatment with chemotherapy, including novel and targeted agents?In patients with LS- or ES-SCLC who achieve a complete or partial response to initial therapy, prophylactic cranial irradiation is recommended (Grade 1B). Remark: The regimen of 25 Gy in 10 daily fractions has the greatest supporting data for safety and efficacy. The panel notes that a recent Japanese study failed to demonstrate survival advantage with PCI in patients with extensive stage SCLC. Upon publication of the mature data from this study, the recommendation for PCI in extensive stage SCLC might be subject to revision
In patients with ES-SCLC who have completed chemotherapy and achieved a complete response outside the chest and complete or partial response in the chest, a course of consolidative thoracic radiotherapy (TRT) is suggested (Grade 2C). Further evaluation of this question is required before a treatment recommendation can be made.
In patients with either LS- or ES-SCLC, four to six cycles of platinum-based chemotherapy with either cisplatin or carboplatin plus either etoposide or irinotecan is recommended over other chemotherapy regimens (Grade 1A). Clinical trials in the US and Europe have not demonstrated a benefit for the Irinotecan regimen over that based on etoposide. In LS disease four cycles is preferred.
Second-line Treatment of SCLC
 In patients with relapsed or refractory SCLC, the administration of second-line, single agent chemotherapy is recommended (Grade 1B). Remark: Reinitiation of the previously administered first-line chemotherapy regimen is recommended in patients who relapse. 6 months from completion of initial chemotherapy. Enrollment in a clinical trial is encouraged. Single agent Topotecan has FDA approval in this context.
Treatment of SCLC in the Elderly
In elderly patients with SCLC, what is the survival and toxicity after treatment with chemotherapy or radiation?In elderly patients with LS-SCLC and good performance status (PS) (Eastern Cooperative Oncology Group [ECOG] 0-2), treatment with platinum-based chemotherapy plus TRT is suggested, with close attention to management of treatment-related toxicity (Grade 2B).
In elderly patients with ES-SCLC and good PS (ECOG 0-2), treatment with carboplatin-based chemotherapy is suggested (Grade 2A).
In elderly patients with SCLC and poor PS, treatment with chemotherapy is suggested if the poor PS is due to SCLC (Grade 2C).

 

 

ASCO Guideline Disclaimer: The clinical practice guidelines and other guidance published herein are provided by the American Society of Clinical Oncology, Inc. ("ASCO") to assist practitioners in clinical decision making. The information therein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time information is developed and when it is published or read. The information is not continually updated and may not reflect the most recent evidence. The information addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This information does not mandate any particular course of medical care. Further, the information is not intended to substitute for the independent professional judgment of the treating physician, as the information does not account for individual variation among patients. Recommendations reflect high, moderate or low confidence that the recommendation reflects the net effect of a given course of action. The use of words like "must," "must not," "should," and "should not" indicate that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating physician to select other courses of action in individual cases. In all cases, the selected course of action should be considered by the treating physician in the context of treating the individual patient. Use of the information is voluntary. ASCO provides this information on an "as is" basis, and makes no warranty, express or implied, regarding the information. ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.


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