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Non-Small Cell Lung Cancer (NSCLC) Treatment Protocols

Treatment Recommendations, Early or Localized Disease

Stage IB (> 4 cm tumor size) or II disease

Surgery is recommended for patients with stage I B (> 4 cm tumor size) or II non–small cell lung cancer [NSCLC]) and may provide the best possibility for a cure. Surgery (radiation therapy if the patient is not a surgical candidate), with or without adjuvant chemotherapy based on risk factors, for stages IB and II is generally appropriate.

Adjuvant chemotherapy after surgical resection provides an absolute increase in 5-y survival of approximately 5%
; median 5-y overall survival rates range from 45-70%. No benefit has been shown for adjuvant chemotherapy after surgery for stage I disease; the benefit of adding adjuvant chemotherapy increases as disease stage increases.

Stereotactic body radiotherapy (SBRT) may be used in early-stage NSCLC tumors that are smaller than 5 cm and without lymph node involvement. This has become a viable and effective option for patients with early-stage NSCLC who are not surgical candidates and in those with significant co-morbidities. Studies show high local control rates (approximately 90%) for these patients. However, the protocols for SBRT have varied among the published studies.

Adjuvant chemotherapy regimens for stage IB or II NSCLC

With chemotherapy for stage IB or II NSCLC, the goal is to complete four cycles. Acceptable adjuvant chemotherapy regimens include the following:

Cisplatin 50 mg/m2 IV on days 1 and 8 plus vinorelbine 25 mg/m2 IV on days 1, 8, 15, and 22 every 28 d
or

Cisplatin 100 mg/m2 IV on day 1 plus  vinorelbine 30 mg/m2 on days 1, 8, 15, and 22 every 28 d
or

Cisplatin 75-80 mg/m2 IV on day 1 plus  vinorelbine 25-30 mg/m2 IV on days 1 and 8 every 21 d
or

Cisplatin 100 mg/m2 IV on day 1 plus etoposide 100 mg/m2 IV on days 1-3 every 28 d
 or

Cisplatin 80 mg/m2 IV on days 1, 22, 43, and 64 plus vinblastine 4 mg/m2 IV on days 1, 8, 15, 22, and 29; then  every 2 wk after day 43 until completion of cisplatin every 21 d
or

Cisplatin 75 mg/m2 IV on day 1 plus gemcitabine 1250 mg/m2 on days 1 and 8 every 21 d
or

Cisplatin 75 mg/m2 IV on day 1 plus docetaxel 75 mg/m2 IV on day 1 every 21 d
 or

Cisplatin 75 mg/m2 IV on day 1 plus pemetrexed 500 mg/m2 IV on day 1 every 21 d (for non-squamous histologies)

Patients with comorbidities or patients not able to tolerate cisplatin may alternatively use one of the following regimens for a goal of four cycles:

Carboplatin AUC 6 IV on day 1 plus paclitaxel 200 mg/m2 IV on day 1 every 21 d
(see the Carboplatin AUC Dose Calculation [Calvert formula] calculator)

Carboplatin AUC 5 IV on day 1 plus gemcitabine 1000 mg/m2 IV on day 1 and 8 every 21 d 

Carboplatin AUC 5 IV on day 1 and pemetrexed 500 mg/m2 IV on day 1 every 21 d (for non-squamous histologies) 

Consider the following in patients with completely resected stage IB-IIIA EGFR mutation–positive NSCLC who received previous adjuvant chemotherapy or are ineligible to receive platinum-based chemotherapy:

Osimertinib 80 mg PO daily, until disease recurrence, or unacceptable toxicity, or for up to 3 years

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