New NCCN Recommendations for Non-Small-Cell Lung Cancer

FORT LAUDERDALE, Florida—The National Comprehensive Cancer Network (NCCN) 2001 guideline for non-small-cell lung cancer (NSCLC) now calls for a "multidisciplinary evaluation" of patients with NSCLC as the standard of care.

"Many NSCLC patients need to see several specialists," said Mark G. Kris, MD, of Memorial Sloan-Kettering Cancer Center. "It may be an oncologist and surgeon or medical oncologist and radiation oncologist—but getting the input of multiple specialists and giving multiple therapies probably will enhance the outcome," he said.

Dr. Kris and David S. Ettinger, MD, of Johns Hopkins Oncology Center, presented the updated NSCLC guideline during the Sixth Annual NCCN Conference: Practice Guidelines and Outcomes Data in Oncology.

Dr. Ettinger addressed the issue of positron emission tomography (PET) scans—a new option in this year’s guideline. "We do know that PET is more sensitive and more specific then the CT scan and the chest x-ray. The bigger issue down the pike, now that we have spiral CTs, concerns small lesions: Do you really need a PET scan for a peripheral lesion that’s less than 1 cm? So I think this area of the PET scan is in evolution," Dr. Ettinger said.

The panel recommended PET scans as optional because the PET scanner is too early in its development to be recommend as part of the routine evaluation of NSCLC.

"Many institutions do not have a PET scanner, and the medical literature on it is not substantial," Dr. Kris said. "The literature that has been published suggests that PET would be useful to help identify patients who would not benefit from a difficult procedure like a major lung surgery."

The 2001 guideline recommends mediastinoscopy, the gold standard in evaluating mediastinal node involvement, for clinical stages I-III disease, but considers it optional in peripheral T1-2 stage I disease. "In T2 disease, mediastinoscopy of a peripheral lesion may be warranted. In a small T1 lesion, many thoracic surgeons say that it won’t be helpful, since, if done, the lymph nodes would be negative," Dr. Ettinger said.

The panel also recommended that no fewer than four N2 lymph node stations be sampled during surgical staging. "Just remember, in surgical resection, the most important thing is to do adequate surgery. It’s important to get a good handle on at least four lymph nodes to understand lymph node involvement," Dr. Ettinger said.

The panel noted that a randomized trial of mediastinal lymph node sampling vs complete lymphadenectomy during pulmonary resection in patients with N0 or N1 NSCLC is currently being conducted by the American College of Surgeons Oncology Group.

Based on the results of an Intergroup cooperative study reported in the New England Journal of Medicine in 1999, there was no consensus about how to treat surgically resected N1 or N2 disease with negative margins. However, the guideline states that radiation therapy is considered optional (category 3, major disagreement among panel members) in N1 disease, and that radiotherapy or combination chemotherapy plus radiotherapy are considered optional (category 2B, nonuniform consensus) for N2 disease.

"These recommendations reflect the relative lack of data that we have in this field. I think that this will change over the next 2 to 5 years," Dr. Kris said.

For metastatic disease, the first-line chemotherapy recommended continues to be a platinum-based regimen. The 2001 guideline has added a second line of chemotherapy; however, there’s no recommendation for third-line therapy.

According to Dr. Kris, trends that could affect future NSCLC guidelines include the use of CT scans for screening high-risk individuals. "We’re seeing smaller tumors. So I think over the next 2 to 5 years, there is going to be a rethinking of how we manage cases. It may be that a 7 mm tumor in the right lower lobe is not going to be treated by a right lower lobectomy," he said.

A second emerging issue is the importance of physician training and experience in thoracic surgery. "A well-publicized trial shows striking differences in mortality between operations done by trained thoracic surgeons vs those without specific thoracic surgery training," Dr. Kris said.