Guideline Essentials: 2023 ESMO Recommendations on Management of Non-oncogene Addicted Metastatic Non-small Cell Lung Cancer

Introduction

In 2023, the European Society for Medical Oncology (ESMO) published guidelines on the diagnosis, treatment, and follow up of patients with oncogene addicted and non-oncogene addicted metastatic non-small cell lung cancer (NSCLC).

This specialist Guidelines overview for secondary care oncologists outlines recommendations on the management of patients with advanced and metastatic non-oncogene addicted NSCLC.  

Please refer to the full ESMO guidelines for all of the recommendations, rationale, and background information. 

General Recommendations 

• Consider histology, molecular pathology, age, performance status, comorbidities, and patient preferences when deciding on treatment strategy
• Offer systemic therapy to all stage IV patients with PS 0–2
• Strongly encourage smoking cessation at all stages of NSCLC because it improves outcomes
• For patients with oligometastatic disease, discuss treatment strategy upfront with the multidisciplinary tumour board (MTB)
• Restrict pemetrexed to non-squamous non-small cell carcinoma.

First-line Treatment Recommendations

Table 1: First-line Treatment Options for Non-oncogene Addicted NSCLC

Second-line Treatment Recommendations

Table 2: Second-line Treatment Options for Non-oncogene Addicted NSCLC

Oligometastatic Disease 

• Offer local radical therapy (LRT) as well as systemic treatment because it may increase overall survival and progression-free survival
• Discuss the choice of LRT with the MTB; radiotherapy and surgery are both safe and effective
• In most cases, consider solitary lesions in the contralateral lung as synchronous second primary tumours and, if possible, treat with curative-intent therapy.

Palliative Radiotherapy in Stage IV Disease 

• For patients with haemoptysis and symptomatic airway obstruction, offer external beam radiotherapy (EBRT)
• Consider radiotherapy for symptom control in:
  • haemoptysis
  • symptomatic airway obstruction
  • painful chest wall disease and bone metastasis
  • superior vena cava syndrome
  • soft-tissue or neural invasion
• High-dose radiotherapy does not result in greater levels of palliation
• EBRT alone is more effective than endobronchial brachytherapy (EBB) alone for palliation; however, consider EBB in selected patients previously treated with EBRT who are symptomatic from recurrent endobronchial central obstruction
• Early radiotherapy can relieve neurological symptoms from spinal cord compression. 

Surgery in Stage IV Disease 

• Consider lung resection with therapeutic intent for highly selected patients
• Consider surgery as a salvage procedure for highly selected patients who have primary or metastatic lesions with specific complications that can be treated with surgery
• Manage persisting or recurrent pleural effusions by pleurodesis to improve dyspnoea
  • talc is the preferred agent; for patients who have primary lung cancer, thoracoscopic poudrage may be better than talc slurry injection
  • recurrent malignant pleural effusions can be managed using indwelling pleural catheters and talc poudrage
• For trapped lung caused by thickened visceral pleural peel, consider indwelling pleural catheters or pleuroperitoneal shunts for symptomatic relief. 

Minimally Invasive Procedures in Stage IV Disease 

• The following procedures may be helpful:
  • endoscopy debulking by laser, cryotherapy, or stent placement for symptomatic major airway obstruction or post-obstructive infection
  • endoscopy (endobronchial or by guiding endovascular embolisation) for diagnosis and treatment of haemoptysis
  • vascular stenting for NSCLC-related superior vena cava compression.