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Non-small cell lung cancer

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 Society of Clinical Oncology (ASCO 2023; 2022; 2020), the European Society for Radiotherapy and Oncology (ESTRO/ASTRO 2023), the American Cancer Society (ACS 2023), the Cancer Care Ontario Foundation (CCO/ASCO 2023; 2021), the European Society of Medical Oncology (ESMO 2022; 2021; 2017), the American Association for Thoracic Surgery (AATS/ESTS 2022), the American College of Chest Physicians (ACCP 2021; 2013), and the U.S. Preventive Services Task Force (USPSTF 2021).
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Guidelines

1.Screening and diagnosis

Indications for screening, low-dose computed tomography, ACS
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)

2.Classification and risk stratification

Staging: as per ESMO 2022 guidelines, use the 8th edition of the AJCC/UICC TNM staging system to stage NSCLC.
B
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3.Diagnostic investigations

Initial evaluation: 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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4.Diagnostic procedures

Histopathology: 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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5.Medical management

General principles
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, 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)

6.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

7.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)

8.Specific circumstances

Patients with transformed lung cancer: offer etoposide or cisplatin in patients with NSCLC harboring anEGFR mutation transformed to small cell lung cancer. Consider continuingEGFR 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

9.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

10.Follow-up and surveillance

Assessment of treatment response, non-genotype-driven therapy: 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