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Non-small cell lung cancer

What's new

Updated 2024 ASCO guidelines for the management of non-small cell lung cancer with driver alterations.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of non-small cell lung cancer are prepared by our editorial team based on guidelines from the American Cancer Society (ACS 2024), the American Society of Clinical Oncology (ASCO 2024,2023,2022,2020), the World Association for Bronchology and Interventional Pulmonology (WABIP 2024), the Cancer Care Ontario Foundation (CCO/ASCO 2023), the European Society for Radiotherapy ...
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Screening and diagnosis

Indications for screening, low-dose CT
As per ACS 2024 guidelines:
Obtain annual screening for lung cancer with low-dose CT in asymptomatic individuals aged 50-80 years being current smokers or former smokers with a ≥ 20 pack-year smoking history, regardless of the number of years since quitting smoking.
B
Provide evidence-based smoking cessation counseling and offer interventions to current smokers before starting lung cancer screening. Engage individuals in a shared decision-making discussion about the benefits, limitations, and harms of lung cancer screening. Stop screening in individuals with comorbidities substantially limiting life expectancy.
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  • Indications for screening (other modalities)

  • Indications for screening (requirements for screening programs)

Classification and risk stratification

Staging: as per ESMO 2023 guidelines, use the 8th edition of the AJCC/UICC TNM staging system to stage NSCLC.
B
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Diagnostic investigations

Initial evaluation: as per ACCP 2013 guidelines, obtain a thorough evaluation to provide an initial clinical assessment of tumor stage in patients with known or suspected lung cancer.
B
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Diagnostic procedures

Histopathology: as per ACCP 2013 guidelines, report the histologic type, tumor size and location, tumor grade (if appropriate), lymphovascular invasion, pleural involvement, surgical margins, and status and location of lymph nodes by station during pathological evaluation.
B
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Medical management

General principles
As per ACCP 2013 guidelines:
Consider ensuring timely and efficient delivery of care in patients with known or suspected lung cancer.
C
Consider using a multidisciplinary team approach in patients with lung cancer requiring multimodality therapy.
C

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  • Management of early-stage disease (pathological staging)

  • Management of early-stage disease (surgery, indications)

  • Management of early-stage disease (surgery, approach)

  • Management of early-stage disease (surgery, technique)

  • Management of early-stage disease (surgery, lymph node dissection)

  • Management of early-stage disease (primary radiotherapy)

  • Management of early-stage disease (adjuvant chemotherapy)

  • Management of early-stage disease (adjuvant targeted therapy)

  • Management of early-stage disease (adjuvant immunotherapy)

  • Management of early-stage disease (adjuvant radiotherapy)

  • Management of early-stage disease (radiofrequency ablation)

  • Management of locally advanced disease (imaging for staging)

  • Management of locally advanced disease (pathological staging)

  • Management of locally advanced disease (general principles of management)

  • Management of locally advanced disease (neoadjuvant therapy)

  • Management of locally advanced disease (surgical resection)

  • Management of locally advanced disease (adjuvant chemotherapy)

  • Management of locally advanced disease (adjuvant targeted therapy)

  • Management of locally advanced disease (adjuvant radiotherapy)

  • Management of locally advanced disease (consolidation immunotherapy)

  • Management of locally advanced disease (definitive chemoradiotherapy)

  • Management of locally advanced disease (prophylactic cranial irradiation)

  • Management of locally advanced disease (salvage surgery)

  • Management of locally advanced disease (palliative therapy)

  • Management of metastatic disease (initial assessment)

  • Management of metastatic disease (imaging for staging)

  • Management of metastatic disease (biopsy and histopathology)

  • Management of metastatic disease (molecular testing)

  • Management of metastatic disease (general principles of management)

  • Management of metastatic disease (first-line therapy, any PD-L1 status)

  • Management of metastatic disease (first-line therapy, PD-L1 < 50%)

  • Management of metastatic disease (first-line therapy, PD-L1 >= 50%)

  • Management of metastatic disease (first-line therapy, ineligible for immunotherapy)

  • Management of metastatic disease (second- and third-line therapy)

  • Management of metastatic disease (maintenance therapy)

  • Management of metastatic disease (genotype-driven therapy, general principles)

  • Management of metastatic disease (genotype-driven therapy, EGFR mutation)

  • Management of metastatic disease (genotype-driven therapy, BRAF mutation)

  • Management of metastatic disease (genotype-driven therapy, KRAS G12C mutation)

  • Management of metastatic disease (genotype-driven therapy, RET fusion)

  • Management of metastatic disease (genotype-driven therapy, ALK rearrangement)

  • Management of metastatic disease (genotype-driven therapy, ROS1 rearrangement)

  • Management of metastatic disease (genotype-driven therapy, HER2 mutation)

  • Management of metastatic disease (genotype-driven therapy, MET mutation)

  • Management of metastatic disease (genotype-driven therapy, NTRK fusion)

  • Management of metastatic disease (salvage surgery)

  • Management of metastatic disease (oligometastatic disease)

  • Management of metastatic disease (isolated brain metastasis)

  • Management of metastatic disease (isolated adrenal gland metastasis)

  • Management of metastatic disease (elderly patients)

  • Management of metastatic disease (palliative care)

  • Symptomatic management (pain control)

  • Symptomatic management (cough)

  • Symptomatic management (hemoptysis)

  • Symptomatic management (airway obstruction)

  • Symptomatic management (pleural effusion)

  • Symptomatic management (trapped lung)

  • Symptomatic management (tracheoesophageal fistulas)

  • Symptomatic management (superior vena cava syndrome)

  • Symptomatic management (neurologic symptoms)

  • Symptomatic management (spinal cord compression)

  • Symptomatic management (bone symptoms)

  • Symptomatic management (psychological symptoms)

Nonpharmacologic interventions

Smoking cessation: as per ESMO 2017 guidelines, advise smoking cessation in all patients with NSCLC. Offer combined behavior techniques and pharmacotherapy.
A

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  • Alternative and complementary therapies

Perioperative care

Preoperative cardiorespiratory assessment: as per ESMO 2017 guidelines, assess the cardiopulmonary fitness of the patient with non-metastatic NSCLC for treatment decision-making. Obtain a precise assessment of cardiac and pulmonary function to estimate the risk of operative morbidity before surgical resection. Use the recalibrated RCRI for cardiac assessment.
B
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  • Perioperative thromboprophylaxis (lobectomy/segmentectomy)

  • Perioperative thromboprophylaxis (pneumonectomy)

Surgical interventions

Lung transplantation: as per ISHLT 2021 guidelines, limit lung transplantation to very select cases of lung-limited adenocarcinoma in situ, minimally invasive adenocarcinoma, or lepidic predominant adenocarcinoma in whom:
surgical resection is not feasible either because of multifocal disease or significant underlying pulmonary disease
multifocal disease has resulted in significant lung restriction and respiratory compromise
medical oncology therapies have failed or are contraindicated
lung transplant is expected to be curative.
E

Specific circumstances

Patients with transformed lung cancer: as per ASCO/CCO 2023 guidelines, offer etoposide or cisplatin in patients with NSCLC harboring an EGFR mutation transformed to small cell lung cancer. Consider continuing EGFR inhibitor with chemotherapy.
B

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  • Patients with central lung cancer (bronchial intraepithelial neoplasia)

  • Patients with central lung cancer (early-stage disease)

  • Patients with central lung cancer (locally advanced disease)

  • Patients with central lung cancer (metastatic disease)

  • Patients with central lung cancer (follow-up)

  • Patients with Pancoast tumor (evaluation)

  • Patients with Pancoast tumor (neoadjuvant therapy)

  • Patients with Pancoast tumor (surgical resection)

  • Patients with Pancoast tumor (definitive and palliative therapy)

  • Patients with tumors invading the chest wall

  • Patients with additional pulmonary nodules (same lobe)

  • Patients with additional pulmonary nodules (ipsilateral different lobe)

  • Patients with additional pulmonary nodules (contralateral lobe)

  • Patients with multifocal lung cancer (evaluation)

  • Patients with multifocal lung cancer (management)

  • Patients with second primary lung cancer

Preventative measures

Smoking cessation: as per ACCP 2021 guidelines, offer evidence-based tobacco cessation treatment in current smokers undergoing low-dose CT screening.
B

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  • Diet

  • Chemoprevention

Follow-up and surveillance

Assessment of treatment response, non-genotype-driven therapy: as per ESMO 2023 guidelines, obtain an assessment of treatment response after 2-3 cycles of systemic therapy using the same initial radiographic investigation that demonstrated tumor lesions.
B
do not obtain routine follow-up PET due to its high sensitivity and relatively low specificity.
B
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  • Assessment of treatment response (genotype-driven therapy)

  • Surveillance after curative-intent therapy

  • Surveillance after palliative therapy