ASCO Updates Guidelines for Adjuvant Systemic, Radiation Therapy for NSCLC

Two randomized trials of patients with completely resected stage IB-IIIA non-small cell lung cancer (NSCLC) prompted an amendment to the American Society of Clinical Oncology (ASCO) Guideline Recommendations to better inform health practitioners of the best available cancer care options in adjuvant systemic therapy and adjuvant radiation therapy.

In 2017, ASCO published guidelines on adjuvant therapy in resected stage I through III NSCLCs. Key evidence from the Wu and Felip trials of 2020 and 2021, respectively, influenced a revision of current recommendations.

The targeted therapy trial from Wu et al in patients with completely resected epidermal growth factor receptor (EGFR) mutant stage IB-IIIA NSCLC found 89% of patients receiving osimertinib versus 52% receiving placebo were alive and disease-free at 24 months (95% CI, 85-92 versus 95% CI, 46-58; overall HR 0.20; 99.12% CI, 0.14-0.30; P < .001).

Further, the Felip et al immunotherapy trial in patients with completely resected stage IB-IIIA NSCLC found at 32 months, the median follow-up disease-free survival was greater for those who received atezolizumab versus best supportive care (HR, 0.66; 95% CI, 0.50 to 0.88; P = .0039).

Members from the original Expert Panel used the GRADE tool to assess the quality of evidence in these trials, and found Wu et al had a high certainty of evidence, whereas Felip et al had a moderate certainty of evidence.

The updated recommendations consist of the following:

For patients with stage IB NSCLC, adjuvant osimertinib is recommended for patients with sensitizing EGFR mutations.

Adjuvant cisplatin-based chemotherapy and/or atezolizumab are not recommended for routine use for patients with stage IB NSCLC. A postoperative multimodality evaluation, including a consultation with a medial oncologist, is recommended to assess benefits and risks of adjuvant therapies for each patient.

For patients with NSCLC in stages IIA, IIB, and IIIA, adjuvant cisplatin-based chemotherapy is recommended. Adjuvant osimertinib is recommended after chemotherapy for patients with tumors with sensitizing EGFR mutations, regardless of PD-L1 status. Adjuvant atezolizumab is recommended for all patients with PD-L1 ≥ 1% after cisplatin-based chemotherapy except for patients with sensitizing EGFR mutations.—Alexa Stoia

Pisters K, Kris M, Gaspar L, et al. Adjuvant Systemic Therapy and Adjuvant Radiation Therapy for Stage I-IIIA Completely Resected Non-Small-Cell Lung Cancer: ASCO Guideline Rapid Recommendation Update. Journal of Clinical Oncology. 2022; 10.1200/JCO.22.00051.