晚期/转移性非小细胞肺癌化疗方案NCCN指南2017V3

SYSTEMIC THERAPY FOR ADVANCED OR METASTATIC DISEASE 晚期或转移性疾病的全身治疗

NSCLC NCCN Guidelines 2017V3
非小细胞肺癌NCCN指南2017V3

ADVANCED DISEASE: 山东省肿瘤医院呼吸肿瘤内科张品良
晚期疾病：

* The drug regimen with the highest likelihood of benefit with toxicity deemed acceptable to both the physician and the patient should be given as initial therapy for advanced lung cancer.
*应该给予最可能受益的、毒性对医患双方都可接受的药物方案作为晚期肺癌的初始治疗。

* Stage, weight loss, performance status, and gender predict survival.
*分期、体重减轻、功能状态以及性别预测生存。

* Platinum-based chemotherapy prolongs survival, improves symptom control, and yields superior quality of life compared to best supportive care.
*与最佳支持治疗相比，以铂类为基础的化疗延长生存期、提高症状控制率并可获得更好的生活质量。

* Histology of NSCLC is important in the selection of systemic therapy.
*在全身治疗的选择中非小细胞肺癌的组织学是重要的。

* New agent/platinum combinations have generated a plateau in overall response rate (≈ 25%–35%), time to progression (4–6 mo), median survival (8–10 mo), 1-year survival rate (30%–40%), and 2-year survival rate (10%–15%) in it patients.
*患者接受新药/铂二联的疗效有个平台：总有效率（≈25%–35%）、至进展时间（4–6个月）、中位生存期（8–10个月）、1年生存率（30%–40%）、2年生存率（10%–15%）。

* Unit patients of any age (performance status 3–4) do not benefit from cytotoxic treatment, except erlotinib, afatinib, or gefitinib for EGFR mutation-positive and crizotinib for ALK-positive tumors of nonsquamous NSCLC or NSCLC NOS.
*PS 3–4、任何年龄段的患者均不能从细胞毒性治疗中获益，除了厄洛替尼、阿法替尼或吉非替尼用于治疗EGFR突变阳性和克唑替尼用于治疗ALK阳性肿瘤的非鳞非小细胞肺癌或非小细胞肺癌非特指。

First-line Therapy
一线治疗

* There is superior efficacy and reduced toxicity for cisplatin/pemetrexed in patients with nonsquamous histology, in comparison to cisplatin/gemcitabine.
*在组织学非鳞癌患者中，与顺铂/吉西他滨相比，顺铂/培美曲塞有优越的疗效和较低的毒性。

* There is superior efficacy for cisplatin/gemcitabine in patients with squamous histology, in comparison to cisplatin/pemetrexed.
*在组织学鳞癌患者中，与顺铂/培美曲塞相比，顺铂/吉西他滨有优越的疗效。

* Two drug regimens are preferred; a third cytotoxic drug increases response rate but not survival. Single-agent therapy may be appropriate in select patients.
* 首选两药方案；第3个细胞毒药物增加有效率，但不改善生存。在选择性的患者中单药治疗可能是合理的。

* Response assessment after 2 cycles, then every 2–4 cycles with CT of known sites of disease with or without contrast or when clinically indicated.
* 两周期后评估疗效，然后每2-4周期或有临床指征时对已知部位强化或平扫CT检查。

Maintenance Therapy
维持治疗

* Continuation maintenance refers to the use of at least one of the agents given in first line, beyond 4–6 cycles, in the absence of disease progression. Switch maintenance refers to the initiation of a different agent, not included as part of the first-line regimen, in the absence of disease progression, after 4–6 cycles of initial therapy.
*继续维持治疗是指在4至6周期后疾病无进展者，使用至少一种一线给予的药物。转换维持治疗是指在4-6周期初始治疗后疾病无进展者，启动一线方案中不包含的一个不同的药物。

Subsequent Therapy
后续治疗

* Response assessment with CT of known sites of disease with or without contrast every 6–12 weeks.
*每6-12周对已知病变部位强化或平扫CT检查评估疗效。

See First-line Systemic Therapy Options for Adenocarcinoma, Large cell, NSCLC NOS on NSCL-F (2 of 4)
见NSCL-F（2/4）腺癌、大细胞癌、非特指非小细胞肺癌的一线全身治疗方案。

See First-line Systemic Therapy Options for Squamous Cell Carcinoma on NSCL-F (3 of 4)
见NSCL-F（3/4）鳞状细胞癌的一线全身治疗方案

First-line Systemic Therapy Options
一线全身治疗方案

Adenocarcinoma, Large Cell, NSCLC NOS (PS 0-1)
腺癌、大细胞肺癌、非小细胞肺癌非特指（PS 0-1）

* Bevacizumab/carboplatin/paclitaxel (category 1)
*贝伐单抗/卡铂/紫杉醇（1类）

* Bevacizumab/carboplatin/pemetrexed
*贝伐单抗/卡铂/培美曲塞

* Bevacizumab/cisplatin/pemetrexed
*贝伐单抗/顺铂/培美曲塞

* Carboplatin/albumin-bound paclitaxel (category 1)
*卡铂/白蛋白结合型紫杉醇（1类）

* Carboplatin/docetaxel (category 1)
*卡铂/多西他赛（1类）

* Carboplatin/etoposide (category 1)
*卡铂/依托泊苷（1类）

* Carboplatin/gemcitabine (category 1)
*卡铂/吉西他滨（1类）

* Carboplatin/paclitaxel (category 1)
*卡铂/紫杉醇（1类）

* Carboplatin/pemetrexed (category 1)
*卡铂/培美曲塞（1类）

* Cisplatin/docetaxel (category 1)
*顺铂/多西他赛（1类）

* Cisplatin/etoposide (category 1)
*顺铂/依托泊苷（1类）

* Cisplatin/gemcitabine (category 1)
*顺铂/吉西他滨（1类）

* Cisplatin/paclitaxel (category 1)
*顺铂/紫杉醇（1类）

* Cisplatin/pemetrexed (category 1)
*顺铂/培美曲塞（1类）

* Gemcitabine/docetaxel (category 1)
*吉西他滨/多西他赛（1类）

* Gemcitabine/vinorelbine (category 1)
*吉西他滨/长春瑞滨（1类）

Adenocarcinoma, Large Cell, NSCLC NOS (PS 2)
腺癌，大细胞肺癌，非小细胞肺癌非特指（PS 2）

* Albumin-bound paclitaxel
*白蛋白结合型紫杉醇

* Carboplatin/albumin-bound paclitaxel
*卡铂/白蛋白结合型紫杉醇

* Carboplatin/docetaxel
*卡铂/多西他赛

* Carboplatin/etoposide
*卡铂/依托泊苷

* Carboplatin/gemcitabine
*卡铂/吉西他滨

* Carboplatin/paclitaxel
*卡铂/紫杉醇

* Carboplatin/pemetrexed
*卡铂/培美曲塞

* Docetaxel
*多西他赛

* Gemcitabine
*吉西他滨

* Gemcitabine/docetaxel
*吉西他滨/多西他赛

* Gemcitabine/vinorelbine
*吉西他滨/长春瑞滨

* Paclitaxel
*紫杉醇

* Pemetrexed
*培美曲塞

First-line Systemic Therapy Options Squamous Cell Carcinoma (PS 0-1)
鳞状细胞癌的一线全身治疗方案（PS 0-1）

* Carboplatin/albumin-bound paclitaxel (category 1)
*卡铂/白蛋白结合型紫杉醇（1类）

* Carboplatin/docetaxel (category 1)
*卡铂/多西他赛（1类）

* Carboplatin/gemcitabine (category 1)
*卡铂/吉西他滨（1类）

* Carboplatin/paclitaxel (category 1)
*卡铂/紫杉醇（1类）

* Cisplatin/docetaxel (category 1)
*顺铂/多西他赛（1类）

* Cisplatin/etoposide (category 1)
*顺铂/依托泊苷（1类）

* Cisplatin/gemcitabine (category 1)
*顺铂/吉西他滨（1类）

* Cisplatin/paclitaxel (category 1)
*顺铂/紫杉醇（1类）

* Gemcitabine/docetaxel (category 1)
*吉西他滨/多西他赛（1类）

* Gemcitabine/vinorelbine (category 1)
*吉西他滨/长春瑞滨（1类）

Squamous Cell Carcinoma (PS 2)
鳞状细胞癌（PS 2）

* Albumin-bound paclitaxel
*白蛋白结合型紫杉醇

* Carboplatin/albumin-bound paclitaxel
*卡铂/白蛋白结合型紫杉醇

* Carboplatin/docetaxel
*卡铂/多西他赛

* Carboplatin/etoposide
*卡铂/依托泊苷

* Carboplatin/gemcitabine
*卡铂/吉西他滨

* Carboplatin/paclitaxel
*卡铂/紫杉醇

* Docetaxel
*多西他赛

* Gemcitabine
*吉西他滨

* Gemcitabine/docetaxel
*吉西他滨/多西他赛

* Gemcitabine/vinorelbine
*吉西他滨/长春瑞滨

* Paclitaxel
*紫杉醇

Albumin-bound paclitaxel may be substituted for either paclitaxel or docetaxel in patients who have experienced hypersensitivity reactions after receiving paclitaxel or docetaxel despite premedication, or for patients where the standard premedications (ie, dexamethasone, H2 blockers, H1 blockers) are contraindicated.
在接受紫杉醇或多西他赛的患者中，尽管预处理用药仍有过敏反应者，或标准预处理用药（即地塞米松、H2受体阻滞剂、H1受体阻滞剂）禁忌者，白蛋白结合型紫杉醇可以取代紫杉醇或多西他赛。

Bevacizumab should be given until progression.
应该给予贝伐单抗直至疾病进展。

Any regimen with a high risk of thrombocytopenia and the potential risk of bleeding should be used with caution in combination with bevacizumab.
任何具有血小板减少高危和潜在出血风险的方案，联合贝伐单抗时均应谨慎。

Criteria for treatment with bevacizumab: non-squamous NSCLC, and no recent history of hemoptysis. Bevacizumab should not be given as a single agent, unless as maintenance if initially used with chemotherapy.
联合贝伐单抗是标准治疗：非鳞非小细胞肺癌并且近期无咯血史。贝伐单抗不应单药给予，除非最初联合化疗使用然后作为维持。

Cisplatin/gemcitabine/necitumumab in the first-line setting and erlotinib or afatinib in the second-line setting are not used at NCCN institutions for these indications related to the efficacy and safety of these agents compared to the efficacy and safety of other available agents.
在NCCN机构中对于这些适应症，基于这些药物的疗效与安全性和其他可用药物的疗效与安全性相比较，顺铂/吉西他滨/necitumumab不用于一线、厄洛替尼或阿法替尼不用于二线。