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Recently, NCCN non-small cell lung cancer (NSCLC) released the V4 version.
What are the main updates in the first 4 versions? Let's take a look! 2021 V4 version updated from 2021 V3 version PD-L1 positive expression (≥50%) first-line treatment of advanced NSCLC-NSCL-31 in PD-L1 ≥50% and driver gene negative, and no PD-1/PD-L1 inhibition Among the NSCLC patients with drug contraindications, for PS 0-2 adenocarcinoma, large cell carcinoma, and non-specific NSCLC patients, cemiplimab-rwlc (class 1) is listed as a priority recommendation.
The 2021 V3 version is updated from the 2021 V2 version of the clinical evaluation, and the pre-treatment evaluation-NSCL-3 footnote q is revised to: The surgical or biopsy tissue of patients with stage IB-IIIA requires EGFR mutation detection (also applicable to NSCL-6 and NSCL-7 ).
Surgical findings-NSCL-4 For patients with stage IB-IIIA negative margins (R0), osimertinib (category 2A) is recommended as adjuvant therapy.
Clinical manifestations-NSCL-6 For patients with superior sulcus lung tumors (T3-4, No-1), the previous adjuvant treatment plan was "surgery + chemotherapy" instead of surgery + chemotherapy and osimertinib.
Add footnote w: For the treatment of METex14 skip mutation NSCLC patients with EGFR mutation-positive NSCLC who have previously received adjuvant chemotherapy or are not suitable for platinum-containing chemotherapy-NSCL-29 For METex14 skip mutation NSCLC patients, if the METex14 skip mutation is found before first-line treatment, first-line The treatment priority is to recommend adding Tepotinib (category 2A).
PD-L1 expression positive (≥50%) first-line treatment of advanced NSCLC——NSCL-31 in NSCLC patients with PD-L1≥50% and negative driver genes and no PD-1/PD-L1 inhibitor contraindications, For non-specific patients with adenocarcinoma, large cell carcinoma, and NSCLC with PS 0~2, the level of evidence of nivolumab + ipilimumab + pemetrexed + carboplatin or cisplatin is upgraded from category 2A to category 1 .
In NSCLC patients with PD-L1≥50% and negative driver genes and no PD-1/PD-L1 inhibitor contraindications, for patients with squamous cell carcinoma with PS 0~2, nivolumab + ipi The level of evidence of Lumumab + Paclitaxel + Carboplatin was upgraded from Class 2A to Class 1.
The 2021 V2 version is updated from the 2021 V1 version of the first-line treatment of ALK rearrangement-positive NSCLC-NSCL-23 For patients with ALK rearrangement-positive NSCLC, if ALK rearrangement is found before the first-line treatment, the first-line treatment preferentially recommends adding loratinib ( Type 1).
The 2021 V1 version is updated from the 2020 V8 version of the clinical evaluation, pre-treatment evaluation-NSCL-2 For patients with stage IA (Pt1abc, N0), patients with negative mediastinal lymph nodes were evaluated before treatment.
The initial treatment for medically inoperable patients is For radical radiotherapy, stereotactic ablation radiotherapy (SABR) is best.
Clinical evaluation, pre-treatment evaluation-NSCL-3 for stage IB (pT2a, N0), stage I (cT1abc-T2a, N0), stage II (T1abc-2ab, N1; T2b, N0), IIB (T3, N0) , IIIA (T3, N1) patients, patients with negative mediastinal lymph nodes assessed before treatment, medically inoperable patients (N1) after radical radiotherapy and chemotherapy, sequential valizumab consolidation therapy (Phase III patients are Category 1 recommendation, category 2A recommendation for stage II patients).
Add footnote q: Consider performing EGFR mutation detection on surgical tissue or biopsy tissue of patients with stage IB-IIIA.
Surgical findings-NSCL-4 For patients with stage IB-IIIA with negative margins (R0), osimertinib should be considered for adjuvant therapy.
Add footnote w: For patients with EGFR mutation-positive NSCLC who have received adjuvant chemotherapy or are not suitable for platinum-based chemotherapy.
Clinical manifestations-NSCL-6 pulmonary superior sulcus tumor (T4 expansion, No-1), after initial treatment, potentially resectable patients are assessed as unresectable patients after surgery, and the adjuvant treatment is complete radical chemotherapy (RT+chemotherapy Changed to chemoradiation).
Clinical evaluation-NSCL-13 For patients with stage IVA, preoperative evaluation is increased: FDG PET/CT scan (if not used before), brain enhanced MRI, molecular testing.
Clinical evaluation-NSCL-14 physical status score classification: changed from PS 0-1 to PS 0-2, and PS 2-4 to PS 3-4.
Treatment-NSCL-15 For patients with thoracic diseases that can be treated with curative treatment, the stage is further determined to confirm whether radical treatment is required.
T1-3, N1 patients are recommended for radiotherapy and chemotherapy (preferred plan).
Monitoring after radical treatment-NSCL-16 is used to evaluate whether recurrence, one of the recommended methods is to change from brain MRI to brain enhanced MRI.
Molecular detection of advanced or metastatic non-small cell lung cancer-NSCL-18 For squamous cell carcinoma, delete: never smokers, small sample biopsy, and mixed histological types.
Treatment of EGFR-sensitive mutation-positive patients-the first-line treatment of NSCLC patients with EGFR-sensitive mutations of NSCL-20 The recommended level of erlotinib + bevacizumab in other recommended programs has been upgraded from 2B to 2A, and changed from use under specific circumstances to Other recommended programs.
Follow-up treatment for patients with EGFR sensitive mutations-NSCL-21 isolated lesions are changed to limited metastasis (NSCL-21, NSCL-24, and NSCL-25 are the same).
Add footnote uu: The number of limited metastases is not yet defined.
Clinical trials generally include 3 to 5 metastases.
Follow-up treatment of EGFR sensitive mutation-positive patients-NSCL-22 footnote zz amended to: For patients with central nervous system (CNS) progression or meningeal metastasis, regardless of T790M status, consider using osimertinib.
In the Bloom study, the dose of osimertinib in patients with meningeal metastases was 160 mg.
The first-line treatment of ALK rearrangement-positive NSCLC-NSCL-23 brigatinib is changed from other recommendations to preferred recommendations (category 1).
Treatment of patients with positive ROS1 rearrangement-Entritinib (Class 2A) is added to the follow-up treatment after the first-line treatment of NSCL-26 progresses.
Added footnote eee: Entratinib may be more effective in patients with brain metastases.
Added footnote fff: Entratinib is mainly used for patients with CNS progression after crizotinib treatment.
Treatment of BRAF V600E mutation-positive patients-NSCL-27 dabrafenib single agent was removed from treatment options.
The first-line treatment of verofenib was changed from other recommendations to use under specific circumstances.
METex14 jump mutation NSCLC treatment-NSCL-29 added footnote tt: Pay attention to patients who stopped TKI treatment due to flares, and TKI should be used again if the disease progresses.
PD-L1 positive expression (≥50%) first-line treatment for advanced NSCLC——NSCL-31 For patients with adenocarcinoma, large cell carcinoma, and non-specific NSCLC, nivolumab + ipilimumab is used as the first-line treatment by 2A Class recommendation is upgraded to Class 1 recommendation (same as NSCL-32).
For squamous cell carcinoma, atilizumab as a first-line treatment is upgraded from a category 2A recommendation to a category 1 recommendation.
During the maintenance treatment, Nivolumab + Ipilimumab (Class 2A) were added (the same for NSCL-32).
Systemic treatment for PD-L1<1% and negative patients-NSCL-33 includes patients with adenocarcinoma, large cell carcinoma, unspecified NSCLC and squamous cell carcinoma.
Add footnote rrr: Monitoring during first-line treatment: response assessment is performed after 2 cycles, and then CT for known lesions is performed every 2 to 4 cycles, or CT evaluation is added or evaluation is performed when clinically designated.
Add footnote sss: Monitoring during follow-up treatment: Use CT or enhanced CT to evaluate the response of known lesions every 6-12 weeks.
Reference: NCCN clinical practice guideline in oncology.
Version 4.
2021.
Non-Small Cell Lung Cancer.
NCCN.
org.