Second-line treatments may include docetaxel, erlotinib, or gefitinib, with pemetrexed as an additional option among patients with nonsquamous-cell carcinoma, the updated guideline recommends.

“Patients with EGFR mutations can receive [second-line] chemotherapy or another EGFR inhibitor, depending on initial response,” the guideline authors said.1 “Patients with ALK rearrangements may be offered chemotherapy or ceritinib.”

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For third-line treatment, erlotinib “may be offered for patients with performance status 0 to 3 who had not previously received erlotinib or gefitinib,” according to the update.

“It is still not clear if a patient takes a break from [chemotherapy] but resumes at the first signs of progression that this is inferior to true maintenance treatment,” Dr. Masters said when asked about the evidence base for pausing treatment following initial response to first-line therapy. “This is a reasonable option for some patients.”

The guideline emphasizes that “age alone should not be a factor” in treatment planning, and spotlights the importance of early integration of palliative care with anticancer therapies.1

“Early palliative care is associated with improved survival of patients with advanced lung cancer,” noted David H. Johnson, co-chair of the ASCO Expert Panel. “Hospice care also improves patient quality of life and reduces caregiver distress.”

“There is a growing body of literature to support that early palliative care improves health outcomes for these patients—however, adoption has not been consistent,” commented David Hui, MD, of the MD Anderson Cancer Center’s Department of Palliative Care and Rehabilitation Medicine, Division of Cancer Medicine in Houston, Texas.

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“It is encouraging that ASCO, a major oncology professional organization, has endorsed integrating early palliative care in its cancer treatment guideline,” Dr. Hui told Cancer Therapy Advisor.

“This evidence-based recommendation is in line with the National Comprehensive Cancer Network (NCCN) guideline for lung cancer. This major milestone will likely encourage oncologists in both academic and community settings to make more palliative care referrals early in the disease trajectory. Our next challenge is to ensure that adequate palliative care resources are available for these referrals to take place.”


  1. Masters GA, Temin S, Azzoli CG, et al. Systemic therapy for stage IV non-small-cell lung cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. [published online ahead of print August 31, 2015] J Clin Oncol. doi: 10.1200/JCO.2015.62.1342.