Photo Credit: Nemes Laszlo

The ARS AUS Thoracic Committee developed evidence-based guidelines for treating NSCLC, aiming to optimize clinical practices in various complex scenarios.

The American Radium Society (ARS) Appropriate Use Criteria (AUC) Thoracic Committee developed evidence-based guidelines for treating unresectable locally advanced non-small cell lung cancer (LA-NSCLC), aiming to optimize clinical practices in various complex scenarios. The committee formed these guidelines through a comprehensive literature review and consensus-driven methods, reflecting advancements in radiotherapy and systemic therapy.

“Lung cancer remains the second most frequently diagnosed cancer in both men and women, with a total estimated annual incidence of more than 235,000 cases in the US,” George Rodrigues, MD, PhD, and colleagues wrote in JAMA Oncology. “The lethality of lung cancer remains the leading cause of cancer mortality, with an estimated 130,180 deaths expected to occur in 2022.”

The ARS guidelines recommend standard care for patients with good prognosis, which involves concurrent platinum-based chemoradiation (60-70 Gy) followed by consolidation durvalumab immunotherapy, especially for patients without disease progression. Advanced radiotherapy techniques like intensity-modulated radiotherapy (IMRT) are preferred for their precision, with different fractionation schedules available based on the patient’s performance and pulmonary status. For poor prognosis patients, sequential therapy or radiation alone is advised to minimize toxic effects.

“Previous guidance on the appropriate management of unresectable LA-NSCLC was published by the American College of Radiology in 20108 and updated in 2014,” the authors explained. “Another source of evidence-based and consensus-based guidance for this patient population is from the National Comprehensive Cancer Network practice guidelines in oncology for NSCLC. Other organizational guidelines on unresectable LA-NSCLC also exist from the American Society of Radiation Oncology, European Society of Medical Oncology, and the American Society of Clinical Oncology.”

Updated Recommendations 

The guidelines recommend sequential chemotherapy followed by radiotherapy for those with bulky disease where radical radiotherapy is not feasible upfront. In cases of EGFR-positive unresectable LA-NSCLC, concurrent chemoradiation remains standard, but consolidation immunotherapy is generally deemed inappropriate, suggesting a potential role for tyrosine kinase inhibitors instead.

In symptomatic patients with poor performance status, the guidelines consider palliative radiotherapy schedules like 30 Gy in 10 fractions or 40-45 Gy in 15 fractions to be appropriate. For radical treatment, doses such as 50-55 Gy in 20 fractions are favored. Shared decision-making that balances treatment goals with patient expectations is crucial for these patients.

For asymptomatic patients with poor performance status, treatment may include radiation therapy alone or in combination with systemic therapies, avoiding concurrent chemoradiation due to its potential adverse effects. Managing local recurrence post-primary treatment involves complex decision-making with various surgical, radiotherapeutic, and systemic options available, often necessitating a multidisciplinary approach.

The guidelines underscore the importance of multidisciplinary collaboration and personalized treatment strategies, integrating advances in molecular pathology and systemic therapy. These updated recommendations aim to enhance the care quality for patients with unresectable LA-NSCLC, addressing both radical and palliative treatment scenarios effectively.

“Evidence-based guidance on the management of various unresectable LA-NSCLC scenarios has been provided by the ARS AUC to optimize multidisciplinary patient care for this challenging patient population,” the authors concluded.