[Prevention, Diagnosis, Therapy, and Follow-up of Lung Cancer - Interdisciplinary Guideline of the German Respiratory Society and the German Cancer Society - Abridged Version]

The current S3 Lung Cancer Guidelines are edited with fundamental changes to the previous edition based on the dynamic influx of information to this field:The recommendations include de novo a mandatory case presentation for all patients with lung cancer in a multidisciplinary tumor board before initiation of treatment, furthermore CT-Screening for asymptomatic patients at risk (after federal approval), recommendations for incidental lung nodule management , molecular testing of all NSCLC independent of subtypes, EGFR-mutations in resectable early stage lung cancer in relapsed or recurrent disease, adjuvant TKI-therapy in the presence of common EGFR-mutations, adjuvant consolidation treatment with checkpoint inhibitors in resected lung cancer with PD-L1 ≥ 50%, obligatory evaluation of PD-L1-status, consolidation treatment with checkpoint inhibition after radiochemotherapy in patients with PD-L1-pos. tumor, adjuvant consolidation treatment with checkpoint inhibition in patients withPD-L1 ≥ 50% stage IIIA and treatment options in PD-L1 ≥ 50% tumors independent of PD-L1status and targeted therapy and treatment option immune chemotherapy in first line SCLC patients.Based on the current dynamic status of information in this field and the turnaround time required to implement new options, a transformation to a "living guideline" was proposed.

Continuous hyperfractionated accelerated radiotherapy (CHART) and non-conventionally fractionated radiotherapy in the treatment of non-small cell lung cancer: a review and consideration of future directions

There is a well-established role for radiation treatment in the management of non-small cell lung cancer. As a single modality, it is indicated as a radical treatment option for patients deemed unsuitable for chemotherapy with inoperable locoregional disease or who decline surgery. In this patient group, the evidence shows advantages for accelerated treatment regimes, e.g. continuous hyperfractionated accelerated radiotherapy (CHART). Research efforts should be directed towards dose escalation with the application of the new technologies available. The multi-modality approach of chemoradiotherapy is established in the radical treatment of non-small cell lung cancer in those who are inoperable, radically treatable and fit enough to receive chemotherapy. How best these two modalities are combined remains unclear, and the combination of CHART and other non-conventionally fractionated radiotherapy schedules with chemotherapy and targeted agents is another potentially productive research area.

Combination of radiotherapy and chemotherapy in locally advanced NSCLC

The combination of radiotherapy and chemotherapy is considered to be a standard approach for patients with locally advanced, stage III non-small-cell lung cancer. The current state of the art of combined radiochemotherapy supported by evidence-based data is presented. As shown in the meta-analyses, the concurrent radiochemotherapy gives a superior outcome in terms of survival compared with sequential delivery of both modalities. This is obtained at the expense of higher toxicity, which makes further intensification of radiochemotherapy challenging. Eligibility of patients with non-small-cell lung cancer for such an approach is limited. The new methods to improve treatment results, such as selection of proper strategies, incorporation of molecular agents into combined treatment and radiotherapy technique modifications are discussed.

Chemoradiation for unresectable stage III non-small cell lung cancer

Patients with unresectable stage III nonsmall cell lung cancer (T4, N3, or bulky N2) live longer if they receive chemotherapy before or concurrent with thoracic irradiation. Randomized clinical trials have shown that concurrent chemoradiation is superior to sequential chemotherapy followed by radiation, with a 20% reduction in the risk of death compared with the sequential approach. However, concurrent chemoradiation is more toxic than the sequential approach, with an increased risk of radiation esophagitis, pneumonitis, and cytopenias, including febrile neutropenia. The phase III trials showing the superiority of the concurrent approach all used cisplatin-based chemotherapy and enrolled patients with a good performance status. For patients who are not eligible for cisplatin, or who have a poor performance status, weight loss, or poor lung function, a sequential approach may be used with full doses of chemotherapy followed by radiation. Another approach currently being studied in phase III trials is to use lower doses of chemotherapy concurrent with radiation followed by full-dose chemotherapy after radiation, so-called concurrent followed by consolidation therapy. Treatment should be planned by the radiation and medical oncologist with careful selection of approach based on the patient's fitness, comorbid medical illness, and size and location of the tumor. The goal of treatment is to maximize efficacy and minimize toxicity that may interfere with delivery of drug or radiation. In the future, more effective, less toxic chemotherapy drugs and better radiation techniques should improve outcomes for patients with unresectable stage III non-small cell lung cancer (NSCLC).

Definitive chemoradiotherapy for non-small cell lung cancer with N2 disease

The treatment of NSCLC continues to evolve over time. Newer therapies and techniques help achieve success in this difficult disease. Since the 1970s, one can observe trends in median survival and notice that they have improved from 9 to 10 months to now 15 to 24 months with concurrent chemoradiation. Unfortunately, despite the advances made, most patients still die from their disease. Chemoradiation without induction or consolidation therapy continues to remain the standard of care in this country for unresectable locally advanced NSCLC. Evaluation of epidermal growth factor receptor tyrosine kinase inhibitors and other biologics continue to be investigated but are not considered standard of care yet. Technologies continue to expand including the use of four-dimensional CT scans and PET scans to more accurately plan patients. Future application of molecular profiling to predict patients most likely to benefit from tailored chemotherapeutic approaches is awaited following validation in early- and advanced-stage disease. With continued diligence to testing new ideas in NSCLC, it is hoped that outcomes will continue to improve the lives of patients with this devastating disease.

Phase II study of oral vinorelbine in combination with carboplatin followed by consolidation therapy with oral vinorelbine as single-agent in unresectable localized or metastatic non-small cell lung carcinoma

INTRODUCTION

This phase II study assessed the efficacy and safety of oral vinorelbine given weekly in combination with carboplatin (CBDCA) AUC 5 once every 3 weeks for four cycles in chemonaive patients with advanced non-small cell lung carcinoma (NSCLC), followed by consolidation therapy with single-agent oral vinorelbine in non-progressive patients.

METHODS

Chemonaive advanced NSCLC patients received four cycles of combination therapy with CBDCA AUC 5 day 1 and oral vinorelbine, 60 mg/m2 on days 1, 8 and 15 (cycle 1), dose increased to 80 mg/m2 (cycles 2-4) in absence of grades 3-4 neutropenia (NCI-CTCv2). Consolidation therapy with oral vinorelbine was continued (cycle 5) at same dosage; if dose was decreased during combination therapy, it was given at 60 mg/m2, then increased at 80 mg/m2 (cycle 6) in absence of grades 3-4 neutropenia until PD, toxicity or patient's refusal.

RESULTS

A total of 57 patients were registered and 56 patients were treated (ITT population), median age was 61 years (37-71). Objective response evaluated by RECIST was 17.9% (95% confidence interval, CI [8.9-30.4]) and disease control (CR, PR, NC) 73.2% (95% CI [59.7-84.2]), median progression-free survival 4.3 months (95% CI [3.1-5.1]) with median overall survival 9.7 months (95% CI [7.7-11.9]) and 1-year survival 37.1% (95% CI [24.4, 49.9]). Grades 3-4 neutropenia occurred in 67.9% of patients during combination and 20% during consolidation; febrile neutropenia occurred in 4 patients (7.1%) during combination therapy. Non-hematological toxicities occurred primarily during combination (grade 3 nausea and grade 3 vomiting in 7.1% of patients).

CONCLUSIONS

The combination of oral vinorelbine given weekly in 3-week cycles in combination with carboplatin followed by consolidation therapy with oral vinorelbine as a single-agent was able to achieve efficacy results in line with other doublets including carboplatin in terms of response as well as survival. This regimen reported a good profile of tolerability in the treatment of advanced NSCLC, allowing that this combination can be easily proposed for the palliative care of NSCLC patients where the advantages of carboplatin over cisplatin are still appreciated.

Combined chemo-radiotherapy for locally advanced non-small cell lung cancer: current status and future development

Currently, combinations of chemotherapy and radiotherapy are the standard treatment approach for locally advanced NSCLC patients. Concomitant chemo-radiotherapy, although associated with increased acute toxicity, has demonstrated to be the better strategy over sequential chemoradiotherapy, and it is to be considered a standard approach in patients with good performance status (0-1). However, the approach to locally advanced NSCLC and to chemo-radiotherapy regimens remains heterogeneous among oncologists, and clinical outcomes are yet disappointing. Thus, the search of new strategies is mandatory. The main fields of research aiming at improving the survival of locally advanced NSCLC patients are: the addition of further combination chemotherapy as induction or consolidation to concurrent chemo-radiotherapy, and the integration of molecularly targeted therapies into conventional chemo-radiotherapy regimens.

Induction chemotherapy with carboplatin, irinotecan, and paclitaxel followed by high dose three-dimension conformal thoracic radiotherapy (74 Gy) with concurrent carboplatin, paclitaxel, and gefitinib in unresectable stage IIIA and stage IIIB non-small cell lung cancer

INTRODUCTION

Combined modality therapy is a standard therapy for patients with unresectable stage III non-small cell lung cancer (NSCLC). Gefitinib is active in advanced NSCLC, and in preclinical models, it potentiates the activity of radiation therapy. We investigate the tolerability of gefitinib in combined modality therapy in combination with three-dimensional thoracic conformal radiation therapy (3-dimensional TCRT).

METHODS

Stage III patients with a good performance status were treated with induction chemotherapy (carboplatin area under the curve [AUC] of 5, irinotecan 100 mg/m(2), and paclitaxel 175 mg/m(2) days 1 and 22) with pegfilgrastim support followed by concurrent chemotherapy (carboplatin AUC 2, and paclitaxel 45 mg/m(2) weekly) and gefitinib 250 mg daily beginning on day 43 with 3-dimensional TCRT to 74 Gy.

RESULTS

Between March 2004 and January 2006, 23 patients received treatment on the trial: median age 62 years (range 44-82), 52% female, 61% stage IIIA, 61% performance status 0, 17% > or =5% weight loss, and 91% underwent positron emission tomography staging. Induction chemotherapy with pegfilgrastim support was well tolerated and active (partial response rate, 24%; stable disease, 76%; and early progression, 0%). Twenty-one patients initiated the concurrent chemoradiation, and 20 patients completed therapy to 74 Gy. The primary toxicities of concurrent chemoradiation were grade 3 esophagitis (19.5%) and cardiac arrhythmia (atrial fibrillation) (9.5%). The median progression-free survival and overall survival were 9 months (95% confidence intervals [CI]: 7-13 months) and 16 months (95% CI: 10-20 months), respectively.

CONCLUSIONS

Treatment with induction chemotherapy and gefitinib concurrent with 3-dimensional TCRT has an acceptable toxicity and tolerability, but the survival results were disappointing.

Advances in the treatment of non-small cell lung cancer

While there have been advances in the treatment of lung cancer, they have been marginal in comparison with recent advances in the chemotherapy and molecularly targeted treatment of breast cancer, colorectal cancer and genitourinary cancer. Lung cancer is an extremely difficult disease to treat, and to obtain positive results and to develop new standard treatment. The results of clinical trial on gefitinib and erlotinib suggest that the evaluation of molecular target drugs seems to be quite difficult in unselected patient population and may be different from cytotoxic drugs. We need to find out specific molecular biomarkers for each drug. With global studies in view, it will be essential to obtain even more significant results by sophisticated clinical trials in selected patient populations and contribute to improving the treatment outcome of lung cancer patients.

Phase III trial of maintenance gefitinib or placebo after concurrent chemoradiotherapy and docetaxel consolidation in inoperable stage III non-small-cell lung cancer: SWOG S0023

PURPOSE

Early clinical studies with gefitinib showed promising efficacy and mild toxicity in patients with advanced non-small-cell lung cancer (NSCLC). Thus, gefitinib was an ideal agent to evaluate in a maintenance setting in stage III disease.

PATIENTS AND METHODS

Untreated patients with stage III NSCLC, a performance score of 0 to 1, and adequate organ function were eligible. All patients received cisplatin 50 mg/m(2) on days 1 and 8 plus etoposide 50 mg/m(2) on days 1 to 5, every 28 days for two cycles with concurrent thoracic radiation (1.8- to 2-Gy fractions per day; total dose, 61 Gy) followed by three cycles of docetaxel 75 mg/m(2). Patients whose disease did not progress were randomly assigned to gefitinib 250 mg/d or placebo until disease progression, intolerable toxicity, or the end of 5 years. The planned sample size was 672 patients to confer power of 0.89 to detect a 33% increase over the expected median survival time of 21 months (one-sided P = .025, log-rank test). Random assignment was stratified by stage, histology, and measurable versus nonmeasurable disease.

RESULTS

Enrollment began in July 2001. An unplanned interim analysis conducted in April 2005 rejected the alternative hypothesis of improved survival at the P = .0015 level for 243 randomly assigned patients. The study closed, and preliminary results were reported. Now, with a median follow-up time of 27 months, median survival time was 23 months for gefitinib (n = 118) and 35 months for placebo (n = 125; two-sided P = .013). The toxic death rate was 2% with gefitinib compared with 0% for placebo.

CONCLUSION

In this unselected population, gefitinib did not improve survival. Decreased survival was a result of tumor progression and not gefitinib toxicity.

What is the optimal treatment of stage IIIA-N2 non-small-cell lung cancer after EORTC 08941?

The results of a randomized trial investigating the role of local therapies after induction chemotherapy in patients with stage IIIA-N2 non-small-cell lung cancer lend themselves to a review of the available evidence and speculation about the routine and future treatment in these patients. An algorithm for future treatment is proposed.

Phase I study of induction chemotherapy and concomitant chemoradiotherapy with irinotecan, carboplatin, and paclitaxel for stage III non-small cell lung cancer

BACKGROUND

The aim of this study was to determine the maximum tolerated dose (MTD), dose limiting toxicities (DLTs), and determine the phase II dose for the combination of irinotecan-carboplatin-paclitaxel given as induction chemotherapy and with concomitant chest radiotherapy for patients with Stage III non-small cell lung cancer.

METHODS

Patients with Cancer and Leukemia Group B performance status of 0 to 2, stage IIIA and IIIB NSCLC patients with resectable or unresectable disease were treated with induction chemotherapy (irinotecan 100 mg/m2, carboplatin AUC 5, and paclitaxel 175 mg/m2 days 1 and 22) followed by concomitant chemotherapy (irinotecan, carboplatin, and paclitaxel) and chest radiotherapy (66 Gy for unresectable and 50 Gy for resectable disease) beginning on week 7. The primary objective was to escalate the dose of irinotecan during chemoradiation in sequential cohorts to determine the DLT and MTD of the regimen.

RESULTS

Thirty-eight patients were enrolled (median age 63 years, 57% male, 41% performance status 0, 30% resectable). Induction chemotherapy was tolerable and active (response rate 26%; stable disease 60%). Eight patients did not receive concurrent chemoradiotherapy because of progressive disease (5), death (1), hypersensitivity reaction to paclitaxel (1), and withdrawal of consent (1). Twenty-nine patients received concurrent chemoradiotherapy. The concomitant administration of chest radiotherapy with weekly irinotecan, carboplatin, and paclitaxel was not feasible at the first, second, and third dose levels. DLT was failure to achieve recovery to <or= grade 1 absolute neutrophil count by the day of scheduled chemotherapy administration. Dose de-escalation to irinotecan 30 mg/m2, paclitaxel 40 mg/m2 (with omission of carboplatin) delivered on weeks 2, 3, 5, and 6 of radiotherapy was the MTD. After induction chemotherapy, partial responses, stable disease, and progressive disease was observed in 26%, 60%, and 14% of patients, respectively. After chemoradiotherapy, partial responses were attained in 16 (55%) patients, whereas 12 patients (41%) attained disease stabilization. Median overall survival was 21 months for the entire cohort. Resectable patients had a median survival of 24 months, whereas unresectable patients had a median survival of 19 months. Differences in overall and progression-free survival rates between resectable and unresectable patients was not statistically significant (p = 0.52 and p = 0.90, respectively).

DISCUSSION

Carboplatin, paclitaxel, and irinotecan with concurrent chemoradiotherapy was poorly tolerated as a result of neutropenia. Although dose de-escalation was required for delivery of the regimen, the response rates and survival outcomes were comparable to other similar regimens.

Hot topics and landmark studies from the 43rd annual meeting of the American Society of Clinical Oncology

The results of several preclinical and clinical studies were reported by oncology professionals at the 43rd American Society of Clinical Oncology (ASCO) meeting, the largest international forum in which the latest achievements in cancer research are annually presented. The central theme this year was 'Translating Research into Practice', emphasizing the goal of forging stronger links between basic research and clinical practice. This review offers a critical, summarized selection of several of the foremost studies presented at the meeting. The focus is on the findings from randomized phase III trials that, in the authors' opinion, are most likely to have an immediate effect on clinical practice.