July 23, 2024

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2021 edition of NCCN Guidelines for Non-Small Cell Lung Cancer


2021 edition of NCCN Guidelines for Non-Small Cell Lung Cancer.  

The National Comprehensive Cancer Network (NCCN) publishes various clinical practice guidelines for malignant tumors every year, which have been recognized and followed by clinicians around the world.


NCCN is a non-profit academic organization composed of 21 top cancer centers in the United States. Its purpose is to improve cancer service levels on a global scale and benefit cancer patients.

On November 25 this year, the NCCN official website released the first edition of the clinical practice guidelines for non-small cell lung cancer (NSCLC) in 2021. Let us learn about it together!





Targets that NSCLC needs to detect

The latest version of NSCLC NCCN guidelines recommends that lung cancer patients should be tested for EGFR, ALK, ROS1, BRAF, KRAS, NTRK, PD-L1 and emerging targets MET, RET, HER2, and tumor mutation burden (TMB).


Targeted adjuvant therapy: Osimertinib is recommended for the first time in patients with operable EGFR mutations.


The disease-free survival (DFS) data of the ADAURA randomized phase III clinical trial led by Professor Wu Yilong clearly supports the use of the third-generation EGFR tyrosine kinase inhibitor (TKI)-ossitinib as an early-stage EGFR-mutant NSCLC patient. Standard treatment after tumor removal.


For EGFR mutation-positive NSCLC, patients who have received adjuvant chemotherapy or are not suitable for adjuvant chemotherapy, osimertinib can be used.


Osimertinib’s indications for adjuvant therapy have been granted priority review by the U.S. Food and Drug Administration (FDA) and are expected to be approved as soon as possible.





The first-line treatment of advanced EGFR lung cancer patients, the status of the joint program improves

In the first-line treatment of advanced NSCLC with EGFR mutations, this update raises the recommended level of erlotinib + bevacizumab from 2B to 2A, and adjusts the recommended method from “available under certain circumstances” to “other recommendations” .


The above recommendation is based on the results of the NEJ026 phase III study: Compared with erlotinib single agent, erlotinib + bevacizumab first-line treatment of EGFR mutation patients prolonged the median progression-free survival (PFS), which was 16.9 vs. 13.3 months (P=0.016).





ALK first-line treatment: brigatinib selected

In terms of ALK rearrangement, the first-line treatment of aletinib still ranks first in the preferred recommendation, while another second-generation ALK-TKI brigatinib has jumped from the previous “other recommendation” to the “preferred recommendation”.


The ALTA-1L study showed that compared with crizotinib, the median PFS of patients who had not received ALK-TKI before treatment with brigatinib was significantly prolonged, which was 24.0 vs 11.0 months (P<0.0001).




Entratinib becomes the preferred recommendation for ROS1 brain metastasis

In terms of ROS1 rearrangement, the guidelines recommend that the first-line treatment is preferably entritinib or crizotinib, and ceritinib is the other recommendation. In this update, entratinib is added as an option for follow-up treatment.


It is mentioned in the footnote that Entritinib may be more suitable for patients with brain metastases in the first-line treatment; Entritinib is also the first choice for patients with brain metastases after crizotinib resistance.




BRAF mutation medication: dual-target program is the only first-line priority recommendation

In this update, the recommendation of dabrafenib monotherapy is removed, and the first-line preferred recommendation is dabrafenib + trametinib.


The NCCN guidelines recommend a treatment plan of dabrafenib (150 mg bid) combined with trametinib (2 mg qd). The objective response rate (ORR) is 64%, the disease control rate (DCR) is 72%, and the PFS is 9.7 months.




MET amplification is highly valued

The NCCN guidelines list some potential targets for new targeted therapies, including high-level MET amplification.


The NCCN guidelines recommend crizotinib and capmatinib as currently available therapeutic drugs.



Immunotherapy: Pembrolizumab’s status remains unchanged. Nivolizumab + Ipilimumab is listed as a level 1 recommendation

For patients with advanced NSCLC with a driver gene-negative PD-L1 expression of ≥50%, pembrolizumab (level 1) monotherapy has remained unchanged as the preferred recommendation. In this update, atelizumab as a single agent was upgraded from grade 2A to grade 1.


Based on the CheckMate-227 Phase III study, the recommended level of nivolumab + ipilimumab has also changed from level 2A to level 1.


For people with high PD-L1 expression, the “no chemotherapy” era may not be far away.


The dream of lung cancer becoming a chronic disease is gradually being realized.






(source:internet, reference only)

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