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 This is an original JCO publication from 2017. Please visit the JCO website to access the full articles.


Adjuvant Chemotherapy and Adjuvant Radiation Therapy for Stages I-IIIA Completely Resected Non–Small-Cell Lung Cancers: American Society of Clinical Oncology/Cancer Care Ontario Clinical Practice Guideline Update


 

 Authors

Mark G. Kris, Laurie E. Gaspar, Jamie E. Chaft, Erin B. Kennedy, Christopher G. Azzoli, Peter M. Ellis, Steven H. Lin, Harvey I. Pass, Rahul Seth, Frances A. Shepherd, David R. Spigel, John R. Strawn, Yee C. Ung, and Michael Weyant

THE BOTTOM LINE

Adjuvant Systemic Therapy and Adjuvant Radiation Therapy for Stage I to IIIA Completely Resected Non–Small Cell Lung Cancers: American Society of Clinical Oncology/Cancer Care Ontario Clinical Practice Guideline Update

Guideline Question

What is the role of adjuvant systemic therapy and adjuvant radiation therapy in patients with completely resected stage I to IIIA non–small-cell lung cancers (NSCLCs)?

Target Population

Patients with completely resected stage I to IIIA NSCLCs (completely resected, defined as no macroscopic disease and uninvolved resection margins pathologically after surgery).

Target Audience

Surgical oncologists, medical oncologists, radiation oncologists, and other clinicians who treat patients in the target population.

Methods

An Expert Panel was convened to update clinical practice guideline recommendations based on a systematic review of the medical literature.

Recommendations

Adjuvant systemic therapy for NSCLCs:

Recommendation 1.1. Stage IA: Adjuvant chemotherapy is not recommended (Type: Evidence based and Panel consensus; Harms outweigh benefits; Evidence quality: Moderate3 ; Strength of recommendation: Strong).

Recommendation 1.2. Stage IB: Adjuvant cisplatin-based chemotherapy is not recommended for routine use. A postoperative multimodality evaluation, including a consultation with a medical oncologist, is recommended to assess benefits and risks of adjuvant chemotherapy for each patient. Factors other than tumor stage to consider when making a recommendation for adjuvant chemotherapy are outlined after the adjuvant systemic therapy section of this guideline (Type: Evidence based and Panel consensus; Benefits outweigh harms, especially in patients with larger tumors; Evidence quality: Intermediate3 ; Strength of recommendation: Moderate).

Recommendation 1.3. Stages IIA/B and IIIA: Adjuvant cisplatin-based chemotherapy is recommended (Type: Evidence based and Panel consensus; Benefits outweigh harms; Evidence quality: High3; Strength of recommendation: Strong).

Adjuvant radiation therapy for NSCLCs:

Recommendation 2.1. Stages IA/B and IIA/B: Adjuvant radiation therapy is not recommended (Type: Evidence based and Panel consensus; Harms outweigh benefits; Evidence quality: Intermediate; Strength of recommendation: Strong2).

Recommendation 2.2. Stage IIIA (N2): Adjuvant radiation therapy is not recommended for routine use. A postoperative multimodality evaluation, including a consultation with a radiation oncologist, is recommended to assess benefits and risks of adjuvant radiotherapy for each patient with N2 disease (Type: Evidence based and Panel consensus; Benefits outweigh harms; Evidence quality: Intermediate4; Strength of recommendation: Moderate).

Comparison of the 2016 Updated Recommendations With the Previous 2007 Version of This Guideline

The recommendations for adjuvant systemic therapy or adjuvant radiation therapy contained in this guideline update do not differ substantively from the 2007 version of this guideline in terms of recommendations for or against the delivery of adjuvant therapy options across various stages. This updated version of the guideline does provide direction within the recommendations for a multimodality evaluation that includes a medical oncologist or a radiation oncologist for stage IB and IIIA resected NSCLCs, respectively. Please see Data Supplement 3 for a direct comparison of the 2007 and 2016 recommendations.

Additional Resources

More information, including a Data Supplement, a Methodology Supplement with information about evidence quality and strength of recommendations, slide sets, and clinical tools and resources, is available at www.asco.org/lung-cancer-guidelines and www.asco.org/guidelineswiki. Patient information is available at www.cancer.net.

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

SUMMARY OF RECOMMENDATIONS

Clinical QuestionRecommendationEvidence Rating
What is the overall survival (OS) benefit of adjuvant systemic therapy in patients with completely resected stage I to IIIA NSCLCs?Stage IA: Adjuvant chemotherapy is not recommended.

Type: Evidence based and Panel consensus

Harms outweigh benefits

Evidence quality: Intermediate1

Strength of recommendation: Strong

Stage IB: Adjuvant cisplatin-based chemotherapy is not recommended for routine use. A postoperative multimodality evaluation, including a consultation with a medical oncologist, is recommended to assess benefits and risks for adjuvant chemotherapy for each patient.

Type: Evidence based and Panel Consensus

Benefits outweigh harms, especially in patients with larger tumors

Evidence quality: Intermediate1

Strength of recommendation: Moderate

Stages IIA/B and IIIA: Adjuvant cisplatin-based chemotherapy is recommended.

Type: Evidence based and Panel consensus

Benefits outweigh harms

Evidence quality: High1

Strength of recommendation: Strong

What is the OS benefit of adjuvant radiation therapy in patients with completely resected stage I to IIIA NSCLCs?Stage IA/B and IIA/B: Adjuvant radiation therapy is not recommended.

Type: Evidence based and Panel consensus

Harms outweigh benefits

Evidence quality: Intermediate

Strength of recommendation: Strong2

Stage IIIA: Adjuvant radiation therapy is not recommended for routine use. A postoperative multimodality evaluation, including a consultation with a radiation oncologist, is recommended to assess benefits and risks of adjuvant radiotherapy in patients with N2 disease.

Type: Evidence based and Panel consensus

Benefits outweigh harms

Evidence quality: Intermediate3

Strength of recommendation: Moderate

References

1. Bradbury P, Sivajohanathan D, Chan A, et al: Postoperative adjuvant systemic therapy in completely resected non–small-cell lung cancer. Clin Lung Cancer [epub ahead of print on July 12, 2016]

2. Pisters KM, Evans WK, Azzoli CG, et al: Cancer Care Ontario and American Society of Clinical Oncology adjuvant chemotherapy and adjuvant radiation therapy for stages I-IIIA resectable non small-cell lung cancer guideline. J Clin Oncol 25:5506-5518, 2007

3. Rodrigues G, Choy H, Bradley J, et al: Adjuvant radiation therapy in locally advanced non-small cell lung cancer: Executive summary of an American Society for Radiation Oncology (ASTRO) evidence-based clinical practice guideline. Pract Radiat Oncol 5:149-155, 2015

 

    

 

 

 

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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