New Lung Cancer Guidelines Advise Adjuvant Therapy Early

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March 10, 2008 (Hollywood, Florida) — Adjuvant cisplatin-based chemotherapy reduces the risk for death in patients with stage 2 or 3 disease who have already had a resection, experts say. The group, presenting here at the National Comprehensive Cancer Network (NCCN) 13th Annual Conference, also recommend that adjuvant therapy be considered for patients with stage 1B disease. For patients with stage 3A disease, they suggest the addition of radiotherapy.

Drs. David Ettinger and Mark Kris presenting at the meeting.

The team presented an update to the non–small-cell lung cancer guidelines. David Ettinger, MD, from the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins in Baltimore, Maryland, was 1 of the presenters reporting on the changes.

"At the present time, the NCCN panel does not recommend the routine use of screening computed tomography (CT) as standard clinical practice," Dr. Ettinger told the meeting.

Despite recent data demonstrating that screening can detect stage 1 lung cancer, the panel remains concerned about the potential risks of such routine use. "The jury is still out on whether CT screening decreases mortality," said copresenter Mark Kris, MD, from Memorial Sloan-Kettering Cancer Center in New York.

Instead, the group recommends that high-risk patients participate in a clinical trial evaluating CT screening. If a trial is not available or the individual is not eligible to participate, then the patient should be referred to a center of excellence with expertise in radiology, pathology, cytology, thoracic surgery, and with general expertise in lung cancer treatment.

Smoking Still a Major Concern

The experts that report they are disturbed by the prevalence of smoking among patients. "Stop cigarette smoking and you stop lung cancer," Dr. Kris emphasized. During the discussion period following the session, a number of attendees lamented the devastating effect the tobacco industry has had, and they said they are troubled by the US government's reliance on tax dollars from the sale of cigarettes.

But, Dr. Kris told the meeting, "we increasingly have the ability to cure. Tens of thousands of patients are cured of lung cancer every year." He added that the era of personalized medicine has arrived in lung cancer and holds even more promise for patients.

For stage 3A non–small-cell lung cancer, the panel recommends multimodality therapy as the standard of care. "Cure is the goal of treatment," Dr. Kris noted. Targeted agents are also showing benefit, he added, and the many therapeutic advances can make even stage 4 disease a chronic disease.

The group continues to recommend bevacizumab (Avastin, Genentech), which appears to improve survival. But the panel cautions that the drug is associated with an increase in serious bleeding, including hemoptysis. They also note that bevacizumab might not be an ideal choice to use with other regimens — particularly if the estimated risk for grade 4 thrombocytopenia is high.

Asked by Medscape Oncology to comment on the updated guidelines, session moderator Mohammad Jahanzeb, MD, from the University of Tennessee Health Science Center in Memphis, commended the work. But, he noted, the update provided no real advance in the description of bevacizumab — that material appears to be virtually unchanged from last year, he said.

Dr. Jahanzeb noted that the recommendation to use adjuvant therapy wherever feasible makes a lot of sense, and he said that the new emphasis on individualized therapy is very promising.

"One of the challenges that remain is the low accrual to clinical trials," Dr. Jahanzeb added. "These low numbers limit our understanding and doctors and patients should work to help remedy the situation."

The complete updated guidelines are available on the NCCN website at: http://www.nccn.org/.

Dr. Ettinger has disclosed having financial relationships with AstraZeneca, Bayer, Bristol-Myers Squibb, Eli Lilly, Genentech, GlaxoSmithKline, Merck, MGI Pharma, Pharmion, Pfizer, and Sanofi-Aventis. Dr. Kris has disclosed having financial relationships to Bayer, Boehringer Ingelheim, GmbH, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Novartis, Pfizer, and Sanofi-Aventis.

National Comprehensive Cancer Network 13th Annual Conference: Guideline Update. Presented March 6, 2008.

Learning Objectives for This Educational Activity

Upon completion of this activity, participants will be able to:

Inform clinicians of the latest medical information on lung cancer treatment as presented at the National Comprehensive Cancer Network 13th Annual Conference.

Describe the relevance of the findings on screening, prevention, and treatment of lung cancer to clinicians in the care of their patients who smoke or who have been diagnosed with lung cancer.

Study Highlights

Treatment of Non–Small-Cell Lung Cancer

Adjuvant cisplatin-based chemotherapy reduces risk for death in those with stage 2 or 3 disease who have had a resection.

Adjuvant cisplatin-based chemotherapy should be considered for those with stage 1B disease.

For patients with stage 3A disease, multimodality treatment is recommended and radiotherapy should be considered.

For stage 3B disease, for chemotherapy following chemoradiation, the recommendation was added for R1,R2 disease after initial treatment with surgery.

The goal of treatment is cure, and with targeted therapy, even stage 4 disease could convert to a chronic disease.

Bevacizumab appears to improve survival but is associated with increased risk of bleeding, including hemoptysis, and may not be ideal when added to other regimens when risk of grade 4 thrombocytopenia is high.

There is an emphasis on individualized treatment.

The surveillance recommendations are for all stages of disease.

Chest CT interval has been changed from "every 6 months" to "every 4 to 6 months" for 2 years for surveillance.

A category of "medically inoperable" is added for treatment recommendations.

Guidelines for the management of thymic malignancies are added.

Screening and Prevention for Lung Cancer

Lung cancer is a unique disease where the etiologic agent is an industry.

More than 90% of cases are caused by voluntary or involuntary (second-hand) cigarette smoking.

Evidence shows a 20% to 30% increase in risk for lung cancer from second-hand smoke exposure from living with a smoker.

Reduction of lung cancer mortality requires effective public health policies to prevent initiation of smoking and tobacco control measures.

The delivery system of lung carcinogens contains the highly addictive substance nicotine, and widespread implementation of the Agency for Healthcare Research and Quality Guidelines are needed to identify, counsel, and treat patients with nicotine addiction.

Patients who are current or former smokers have a significant risk for the development of lung cancer.

Chemopreventive agents are not established, and current or former smokers should be encouraged to enroll in chemoprevention trials.

The NCCN panel does not currently recommend the routine use of screening CT as standard clinical practice despite recent data suggesting that CT can detect stage 1 lung cancer with potential increase in survival.

The panel expressed concern about the potential risks of routine CT screening for lung cancer.

Patients at high risk for lung cancer should be encouraged to participate in trials on CT screening or referred to a center of excellence in radiology, pathology, thoracic surgery, or with general expertise in lung cancer.

Pearls for Practice

Adjuvant cisplatin-based therapy should be considered for stage 1B and added to stage 2 and 3 non–small-cell lung cancer treatment after surgical resection.

Routine CT is not recommended for lung cancer screening.

According to the updated NCCN guidelines on non–small-cell lung cancer, which of the following options is most likely to be a recommendation for adjuvant cisplatin-based therapy?

Adjuvant cisplatin-based therapy should be used for stage 3 disease after resection

Adjuvant cisplatin-based therapy should not be added to stage 2 disease after resection

Adjuvant cisplatin-based therapy should be considered for stage 1A disease

Adjuvant cisplatin-based therapy should not be used for stage 4 disease

Which of the following options best describes the 2008 NCCN recommendations for screening for lung cancer?

Annual CT screening is recommended for all patients who smoke

CT screening is recommended for active and passive smokers

CT screening is not recommended for screening

CT screening is only recommended for those with a family history of lung cancer

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Target Audience

This article is intended for clinicians who want to maintain a current understanding of recent research and evidence in lung cancer screening, prevention, and treatment.

Goal

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

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