Systemic Therapy for Stage IV Non-Small-Cell Lung Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. Systemic Therapy for Stage IV Non-Small-Cell Lung Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. Stereotactic body radiation therapy for early-stage non-small cell lung cancer: Executive Summary of an ASTRO Evidence-Based Guideline. Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology clinical practice guideline update. American Society of Clinical Oncology Clinical Practice Guideline update on chemotherapy for stage IV non-small-cell lung cancer. Treatment of stage III non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Recommendations for the Use of White Blood Cell Growth Factors: American Society of Clinical Oncology Clinical Practice Guideline Update. American Society of Clinical Oncology 2008 clinical practice guideline update: use of chemotherapy and radiation therapy protectants. Adjuvant endocrine therapy for women with hormone receptor-positive breast cancer: american society of clinical oncology clinical practice guideline focused update. Colorectal cancer surveillance: 2005 update of an American Society of Clinical Oncology practice guideline. Preoperative or postoperative therapy for resectable oesophageal cancer: an updated practice guideline. Phase III trial of two versus four additional cycles in patients who are nonprogressive after two cycles of platinum-based chemotherapy in non small-cell lung cancer. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. American Society of Clinical Oncology provisional clinical opinion: epidermal growth factor receptor (EGFR) Mutation testing for patients with advanced non-small-cell lung cancer considering first-line EGFR tyrosine kinase inhibitor therapy. ESTS guidelines for intraoperative lymph node staging in non-small cell lung cancer. Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. Locally Advanced, Unresectable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline. Preoperative or postoperative therapy for stage II or III rectal cancer: an updated practice guideline. Molecular testing guideline for selection of lung cancer patients for EGFR and ALK tyrosine kinase inhibitors: guideline from the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology. Molecular Testing Guideline for Selection of Lung Cancer Patients for EGFR and ALK Tyrosine Kinase Inhibitors: Guideline from the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association Sentinel Lymph Node Biopsy for Patients With Early-Stage Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. Why Do Some Lung Cancer Patients Receive No Anticancer Treatment?
Purpose To provide evidence -based recommendations to up date the American Society of Clinical Oncology guideline on systemic therapy for stage IV non – small-cell lung cancer ( NSCLC ) . Methods An Up date Committee of the American Society of Clinical Oncology NSCLC Expert Panel based recommendations on a systematic review of r and omized controlled trials from January 2007 to February 2014 . Results This guideline up date reflects changes in evidence since the previous guideline . Recommendations There is no cure for patients with stage IV NSCLC . For patients with performance status ( PS ) 0 to 1 ( and appropriate patient cases with PS 2 ) and without an EGFR-sensitizing mutation or ALK gene rearrangement , combination cytotoxic chemotherapy is recommended , guided by histology , with early concurrent palliative care . Recommendations for patients in the first-line setting include platinum-doublet therapy for those with PS 0 to 1 ( bevacizumab may be added to carboplatin plus paclitaxel if no contraindications ) ; combination or single-agent chemotherapy or palliative care alone for those with PS 2 ; afatinib , erlotinib , or gefitinib for those with sensitizing EGFR mutations ; crizotinib for those with ALK or ROS1 gene rearrangement ; and following first-line recommendations or using platinum plus etoposide for those with large-cell neuroendocrine carcinoma . Maintenance therapy includes pemetrexed continuation for patients with stable disease or response to first-line pemetrexed-containing regimens , alternative chemotherapy , or a chemotherapy break . In the second-line setting , recommendations include docetaxel , erlotinib , gefitinib , or pemetrexed for patients with nonsquamous cell carcinoma ; docetaxel , erlotinib , or gefitinib for those with squamous cell carcinoma ; and chemotherapy or ceritinib for those with ALK rearrangement who experience progression after crizotinib . In the third-line setting , for patients who have not received erlotinib or gefitinib , treatment with erlotinib is recommended . There are insufficient data to recommend routine third-line cytotoxic therapy . Decisions regarding systemic therapy should not be made based on age alone . Additional information can be found at http://www.asco.org/ guidelines /nsclc and http://www.asco.org/ guidelines wiki . J Clin Oncol 33:3488 - 3515 . © 2015 by American Society of Clinical Purpose Provide evidence -based recommendations updating the 2015 ASCO guideline on systemic therapy for patients with stage IV non-small-cell lung cancer ( NSCLC ) . Methods The ASCO NSCLC Expert Panel made recommendations based on a systematic review of r and omized controlled trials from February 2014 to December 2016 plus the Cancer Care Ontario Program in Evidence -Based Care 's up date of a previous ASCO search . Results This guideline up date reflects changes in evidence since the previous guideline up date . Fourteen r and omized controlled trials provide the evidence base ; earlier phase trials also informed recommendation development . Recommendations New or revised recommendations include the following . Regarding first-line treatment for patients with non-squamous cell carcinoma or squamous cell carcinoma ( without positive markers , eg , EGFR/ALK /ROS1 ) , if the patient has high programmed death lig and 1 ( PD-L1 ) expression , pembrolizumab should be used alone ; if the patient has low PD-L1 expression , clinicians should offer st and ard chemotherapy . All other clinical scenarios follow 2015 recommendations . Regarding second-line treatment in patients who received first-line chemotherapy  , without prior immune checkpoint therapy , if NSCLC tumor is positive for PD-L1 expression , clinicians should use single-agent nivolumab , pembrolizumab , or atezolizumab ; if tumor has negative or unknown PD-L1 expression , clinicians should use nivolumab or atezolizumab . All immune checkpoint therapy is recommended alone plus in the absence of contraindications . For patients who received a prior first-line immune checkpoint inhibitor , clinicians should offer st and ard chemotherapy . For patients who can not receive immune checkpoint inhibitor after chemotherapy , docetaxel is recommended ; in patients with nonsquamous NSCLC , pemetrexed is recommended . In patients with a sensitizing EGFR mutation , disease progression after first-line epidermal growth factor receptor tyrosine kinase inhibitor therapy , and T790 M mutation , osimertinib is recommended ; if NSCLC lacks the T790 M mutation , then chemotherapy is recommended . Patients with ROS1 gene rearrangement without prior crizotinib may be offered crizotinib , or if they previously received crizotinib , they may be offered chemotherapy PURPOSE This guideline presents evidence -based recommendations for stereotactic body radiation therapy ( SBRT ) in challenging clinical scenarios in early-stage non-small cell lung cancer ( NSCLC ) . METHODS AND MATERIAL S The American Society for Radiation Oncology convened a task force to perform a systematic literature review on 4 key questions addressing : ( 1 ) application of SBRT to operable patients ; ( 2 ) appropriate use of SBRT in tumors that are central ly located , large , multifocal , or unbiopsied ; ( 3 ) individual tailoring of SBRT in " high-risk " clinical scenarios ; and ( 4 ) SBRT as salvage therapy after recurrence . Guideline recommendations were created using a predefined consensus-building methodology supported by American Society for Radiation Oncology-approved tools for grading evidence quality and recommendation strength . RESULTS Although few r and omized trials have been completed for SBRT , strong consensus recommendations based on extensive , consistent publications were generated for several questions , including recommendations for fractionation for central tumors and surgery versus SBRT in st and ard-risk medically operable patients with early-stage NSCLC . Lower quality evidence led to conditional recommendations on use of SBRT for tumors > 5 cm , patients with prior pneumonectomy , T3 tumors with chest wall invasion , synchronous multiple primary lung cancer , and as a salvage therapy after prior radiation therapy . These areas of moderate- and low- quality evidence highlight the importance of clinical trial enrollment as well as the role of prospect i ve data registries . CONCLUSIONS SBRT has an important role to play in treating early-stage NSCLC , particularly for medically inoperable patients with limited other treatment options . Shared decision-making with patients should be performed in all cases to ensure the patient underst and s the risks related to SBRT , the side effects , and the alternative treatments available PURPOSE To provide evidence -based recommendations to practicing oncologists , surgeons , and radiation therapy clinicians to up date the 2005 clinical practice guideline on the use of sentinel node biopsy ( SNB ) for patients with early-stage breast cancer . METHODS The American Society of Clinical Oncology convened an Up date Committee of experts in medical oncology , pathology , radiation oncology , surgical oncology , guideline implementation , and advocacy . A systematic review of the literature was conducted from February 2004 to January 2013 in Medline . Guideline recommendations were based on the review of the evidence by Up date Committee . RESULTS This guideline up date reflects changes in practice since the 2005 guideline . Nine r and omized clinical trials ( RCTs ) met systematic review criteria for clinical questions 1 and 2 ; 13 cohort studies informed clinical question 3 . RECOMMENDATIONS Women without sentinel lymph node ( SLN ) metastases should not receive axillary lymph node dissection ( ALND ) .  Women with one to two metastatic SLNs planning to undergo breast-conserving surgery with whole-breast radiotherapy should not undergo ALND ( in most cases ) . Women with SLN metastases who will undergo mastectomy should be offered ALND . These three recommendation are based on RCTs . Women with operable breast cancer and multicentric tumors , with ductal carcinoma in situ ( DCIS ) who will undergo mastectomy , who previously underwent breast and /or axillary surgery , or who received preoperative/neoadjuvant systemic therapy may be offered SNB . Women who have large or locally advanced invasive breast cancer ( tumor size T3/T4 ) , inflammatory breast cancer , or DCIS ( when breast-conserving surgery is planned ) or are pregnant should not undergo SNB . These recommendations are based on cohort studies and /or informal consensus . In some cases , up date d evidence was insufficient to up date previous recommendations The purpose of this article is to provide up date d recommendations for the treatment of patients with stage IV non-small-cell lung cancer . A literature search identified relevant r and omized trials published since 2002 . The scope of the guideline was narrowed to chemotherapy and biologic therapy . An Up date Committee review ed the literature and made up date d recommendations . One hundred sixty-two publications met the inclusion criteria . Recommendations were based on treatment strategies that improve overall survival . Treatments that improve only progression-free survival prompted scrutiny of toxicity and quality of life . For first-line therapy in patients with performance status of 0 or 1 , a platinum-based two-drug combination of cytotoxic drugs is recommended . Nonplatinum cytotoxic doublets are acceptable for patients with contraindications to platinum therapy . For patients with performance status of 2 , a single cytotoxic drug is sufficient . Stop first-line cytotoxic chemotherapy at disease progression or after four cycles in patients who are not responding to treatment . Stop two-drug cytotoxic chemotherapy at six cycles even in patients who are responding to therapy . The first-line use of gefitinib may be recommended for patients with known epidermal growth factor receptor ( EGFR ) mutation ; for negative or unknown EGFR mutation status , cytotoxic chemotherapy is preferred . Bevacizumab is recommended with carboplatin-paclitaxel , except for patients with certain clinical characteristics . Cetuximab is recommended with cisplatin-vinorelbine for patients with EGFR-positive tumors by immunohistochemistry . Docetaxel , erlotinib , gefitinib , or pemetrexed is recommended as second-line therapy . Erlotinib is recommended as third-line therapy for patients who have not received prior erlotinib or gefitinib . Data are insufficient to recommend the routine third-line use of cytotoxic drugs . Data are insufficient to recommend routine use of molecular markers to select chemotherapy OBJECTIVES Stage III non-small cell lung cancer ( NSCLC ) describes a heterogeneous population with disease presentation ranging from apparently resectable tumors with occult microscopic nodal metastases to unresectable , bulky nodal disease . This review up date s the published clinical trials since the last American College of Chest Physicians guidelines to make treatment recommendations for this controversial subset of patients . METHODS Systematic search es were conducted through MEDLINE , Embase , and the Cochrane Data base for Systematic Review up to December 2011 , focusing primarily on r and omized trials , selected meta-analyses , practice guidelines , and review s. RESULTS For individuals with stage IIIA or IIIB disease , good performance scores , and minimal weight loss , treatment with combined chemoradiotherapy results in better survival than radiotherapy alone . Consolidation chemotherapy or targeted therapy following definitive chemoradiation for stage IIIA is not supported . Neoadjuvant therapy followed by surgery is neither clearly better nor clearly worse than definitive chemoradiation . Most of the arguments made regarding patient selection for neoadjuvant therapy and surgical resection provide evidence for better prognosis but not for a beneficial impact of this treatment strategy ; however , weak comparative data suggest a possible role if only lobectomy is needed in a center with a low perioperative mortality rate . The evidence supports routine platinum-based adjuvant chemotherapy following complete resection of stage IIIA lung cancer encountered unexpectedly at surgery . Postoperative radiotherapy  improves local control without improving survival . CONCLUSIONS Multimodality therapy is preferable in most subsets of patients with stage III lung cancer . Variability in the patients included in r and omized trials limits the ability to combine results across studies and thus limits the strength of recommendations in many scenarios . Future trials are needed to investigate the roles of individualized chemotherapy , surgery in particular cohorts or setting s , prophylactic cranial radiation , and adaptive radiation Purpose To up date the 2006 American Society of Clinical Oncology guideline on the use of hematopoietic colony-stimulating factors ( CSFs ) . Methods The American Society of Clinical Oncology convened an Up date Committee and conducted a systematic review of r and omized clinical trials , meta-analyses , and systematic review s from October 2005 through September 2014 . Guideline recommendations were based on the review of the evidence by the Up date Committee . Results Changes to previous recommendations include the addition of tbo-filgrastim and filgrastim-sndz , moderation of the recommendation regarding routine use of CSFs in older patients with diffuse aggressive lymphoma , and addition of recommendations against routine dose-dense chemotherapy in lymphoma and in favor of high – dose-intensity chemotherapy in urothelial cancer . The Up date Committee did not address recommendations regarding use of CSFs in acute myeloid leukemia or myelodysplastic syndromes in adults . Recommendations Prophylactic use of CSFs to reduce the risk of febrile neutropenia is warranted when the risk of febrile neutropenia is approximately 20 % or higher and no other equally effective and safe regimen that does not require CSFs is available . Primary prophylaxis is recommended for the prevention of febrile neutropenia in patients who are at high risk on the basis of age , medical history , disease characteristics , and myelotoxicity of the chemotherapy regimen . Dose-dense regimens that require CSFs should only be used within an appropriately design ed clinical trial or if supported by convincing efficacy data . Current recommendations for the management of patients exposed to lethal doses of total-body radiotherapy , but not doses high enough to lead to certain death as a result of injury to other organs , include the prompt administration of CSFs . J Clin Oncol 33:3199 - 3212 . © 2015 by American Society of Clinical PURPOSE To up date a clinical practice guideline on the use of chemotherapy and radiation therapy protectants for patients with cancer . METHODS An up date committee review ed literature published since the last guideline up date in 2002 . RESULTS Thirty-nine reports met the inclusion criteria : palifermin and dexrazoxane , three reports ( two studies ) each ; amifostine , 33 reports ( 31 studies ) ; and mesna , no published r and omized trials identified since 2002 . RECOMMENDATIONS Dexrazoxane is not recommended for routine use in breast cancer ( BC ) in adjuvant setting , or metastatic setting with initial doxorubicin-based chemotherapy . Consider use with metastatic BC and other malignancies , for patients who have received more than 300 mg/m(2 ) doxorubicin  who may benefit from continued doxorubicin-containing therapy . Cardiac monitoring should continue in patients receiving doxorubicin . Amifostine may be considered for prevention of cisplatin-associated nephrotoxicity , reduction of grade 3 to 4 neutropenia ( alternative strategies are reasonable ) , and to decrease acute and late xerostomia with fractionated radiation therapy alone for head and neck cancer . It is not recommended for protection against thrombocytopenia , prevention of platinum-associated neurotoxicity or ototoxicity or paclitaxel-associated neuropathy , prevention of radiation therapy-associated mucositis in head and neck cancer , or prevention of esophagitis during concurrent chemoradiotherapy for non-small-cell lung cancer . Palifermin is recommended to decrease severe mucositis in autologous stem-cell transplantation ( SCT ) for hematologic malignancies with total-body irradiation ( TBI ) conditioning regimens , and considered for patients undergoing myeloablative allogeneic SCT with TBI-based conditioning regimens . Data are insufficient to recommend use in the non-SCT setting PURPOSE To up date the ASCO clinical practice guideline on adjuvant endocrine therapy on the basis of emerging data on the optimal duration of treatment , particularly adjuvant tamoxifen . METHODS ASCO convened the Up date Committee and conducted a systematic review of r and omized clinical trials from January 2009 to June 2013 and analyzed three historical trials . Guideline recommendations were based on the Up date Committee 's review of the evidence . Outcomes of interest included survival , disease recurrence , and adverse events . RESULTS This guideline up date reflects emerging data on duration of tamoxifen treatment . There have been five studies of tamoxifen treatment beyond 5 years of therapy . The two largest studies with longest reported follow-up show a breast cancer survival advantage with 10-year duration s of tamoxifen use . In addition to modest gains in survival , extended therapy with tamoxifen for 10 years compared with 5 years was associated with lower risks of breast cancer recurrence and contralateral breast cancer . RECOMMENDATIONS Previous ASCO guidelines recommended treatment of women who have hormone receptor-positive breast cancer and are premenopausal with 5 years of tamoxifen , and those who are postmenopausal a minimum of 5 years of adjuvant therapy with an aromatase inhibitor or tamoxifen followed by an aromatase inhibitor ( in sequence ) . If women are pre- or perimenopausal and have received 5 years of adjuvant tamoxifen , they should be offered 10 years total duration of tamoxifen . If women are postmenopausal and have received 5 years of adjuvant tamoxifen  , they should be offered the choice of continuing tamoxifen or switching to an aromatase inhibitor for 10 years total adjuvant endocrine therapy PURPOSE To up date the 2000 American Society of Clinical Oncology guideline on colorectal cancer surveillance . RECOMMENDATIONS Based on results from three independently reported meta-analyses of r and omized controlled trials that compared low-intensity and high-intensity programs of colorectal cancer surveillance , and on recent analyses of data from major clinical trials in colon and rectal cancer , the Panel recommends annual computed tomography ( CT ) of the chest and abdomen for 3 years after primary therapy for patients who are at higher risk of recurrence and who could be c and i date s for curative-intent surgery ; pelvic CT scan for rectal cancer surveillance , especially for patients with several poor prognostic factors , including those who have not been treated with radiation  ; colonoscopy at 3 years after operative treatment , and , if results are normal , every 5 years thereafter ; flexible proctosigmoidoscopy [ corrected ] every 6 months for 5 years for rectal cancer patients who have not been treated with pelvic radiation  ; history and physical examination every 3 to 6 months for the first 3 years , every 6 months during years 4 and 5 , and subsequently at the discretion of the physician ; and carcinoembryonic antigen every 3 months postoperatively for at least 3 years after diagnosis , if the patient is a c and i date for surgery or systemic therapy .  Chest x-rays , CBCs , and liver function tests are not recommended , and molecular or cellular markers should not influence the surveillance strategy based on available evidence AIMS Oesophageal cancer is an aggressive disease and the optimal therapy for patients with resectable tumours remains unclear . A systematic review and companion practice guideline were published in 2004 ; however , new evidence has become available since the publication of the original report . An up date of the literature search and a revision of the recommendations were undertaken to incorporate the new data . The following research question was addressed : should patients with resectable oesophageal cancer receive preoperative or postoperative therapy together with surgery ? The outcomes of interest were survival , adverse effects and quality of life . MATERIAL S AND METHODS The literature search of the original systematic review was up date d to April 2007 . MEDLINE , EMBASE , Cochrane Library and abstract s from the American Society of Clinical Oncology and the American Society for Therapeutic Radiology and Oncology were search ed for reports of r and omised controlled trials and meta-analyses comparing preoperative or postoperative therapy with surgery alone or other preoperative or postoperative therapy . After the completion of the draft systematic review and practice guideline , the report was distributed through a mailed survey to 133 health care providers in Ontario for review and feedback . RESULTS The up date d literature search yielded eight new r and omised controlled trial reports and seven new meta- analysis reports for consideration , together with the evidence review ed in the original review publication . Of the 31 practitioners who responded to the mailed survey , 80 % agreed with the draft recommendations as stated , 83 % agreed that the report should be approved as a practice guideline and 86 % indicated that they would probably use the guideline in their own practice . CONCLUSIONS Preoperative cisplatin-based chemotherapy plus radiotherapy is recommended as the preferred modality for the management of surgically resectable patients with oesophageal cancer .  Preoperative cisplatin-based chemotherapy alone is an alternative choice for the management of these patients PURPOSE This trial was conducted to determine the optimal duration of chemotherapy in Korean patients with advanced non-small-cell lung cancer ( NSCLC ) . PATIENTS AND METHODS Patients with stages IIIB to IV NSCLC who had not progressed after two cycles of chemotherapy were r and omly assigned to receive either four ( arm A ) or two ( arm B ) more cycles of third-generation , platinum-doublet treatment . RESULTS Of the 452 enrolled patients , 314 were r and omly assigned to the groups . One-year survival rates were 59.0 % in arm A and 62.4 % in arm B , and the difference of 3.4 % ( 95 % CI , -8.0 to 4.8 ) met the predefined criteria for noninferiority . The median time to progression ( TTP ) , however , was 6.2 months ( 95 % CI , 5.7 to 6.7 months ) in arm A and 4.6 months ( 95 % CI , 4.4 to 4.8 months ) in arm B , the difference of which is statistically significant ( P = .001 ) . The frequencies of hematologic and nonhematologic toxicities were similar in the two arms . CONCLUSION This study confirms the noninferiority of overall survival with four cycles compared with six cycles of chemotherapy for the first-line treatment of advanced NSCLC and supports the current American Society of Clinical Oncology guidelines . Notably , patients receiving six cycles of chemotherapy compared with four cycles showed a favorable TTP , suggesting that further investigation of the new strategies of maintenance therapy with less toxic agents after three to four cycles of induction chemotherapy might be warranted to improve survival , with consideration of both ethnicity and pharmacogenomic signatures BACKGROUND Correctly staging lung cancer is important because the treatment options and prognosis differ significantly by stage . Several noninvasive imaging studies and invasive tests are available . Underst and ing the accuracy , advantages , and disadvantages of the available methods for staging non-small cell lung cancer is critical to decision-making . METHODS Test accuracies for the available staging studies were up date d from the second iteration of the American College of Chest Physicians Lung Cancer Guidelines . Systematic search es of the MEDLINE data base were performed up to June 2012 with the inclusion of selected meta-analyses , practice guidelines , and review s. Study design s and results are summarized in evidence tables . RESULTS The sensitivity and specificity of CT scanning for identifying mediastinal lymph node metastasis were approximately 55 % and 81 % , respectively , confirming that CT scanning has limited ability either to rule in or exclude mediastinal metastasis . For PET scanning , estimates of sensitivity and specificity for identifying mediastinal metastasis were approximately 77 % and 86 % , respectively . These findings demonstrate that PET scanning is more accurate than CT scanning , but tissue biopsy is still required to confirm PET scan findings . The needle techniques endobronchial ultrasound-needle aspiration , endoscopic ultrasound-needle aspiration , and combined endobronchial ultrasound/endoscopic ultrasound-needle aspiration have sensitivities of approximately 89 % , 89 % , and 91 % , respectively . In direct comparison with surgical staging , needle techniques have emerged as the best first diagnostic tools to obtain tissue . Based on r and omized controlled trials , PET or PET-CT scanning is recommended for staging and to detect unsuspected metastatic disease and avoid noncurative resections . CONCLUSIONS Since the last iteration of the staging guidelines , PET scanning has assumed a more prominent role both in its use prior to surgery and when evaluating for metastatic disease . Minimally invasive needle techniques to stage the mediastinum have become increasingly accepted and are the tests of first choice to confirm mediastinal disease in accessible lymph node stations . If negative , these needle techniques should be followed by surgical biopsy . All abnormal scans should be confirmed by tissue biopsy ( by whatever method is available ) to ensure accurate staging . Evidence suggests that more complete staging improves patient outcomes PURPOSE An American Society of Clinical Oncology ( ASCO ) provisional clinical opinion ( PCO ) offers timely clinical direction to ASCO 's membership following publication or presentation of potentially practice -changing data from major studies . This PCO addresses the clinical utility of using epidermal growth factor receptor ( EGFR ) mutation testing for patients with advanced non-small-cell lung cancer ( NSCLC ) to predict the benefit of taking a first-line EGFR tyrosine kinase inhibitor ( TKI ) . CLINICAL CONTEXT Patients with EGFR-mutated NSCLC have a significantly higher rate of partial responses to the EGFR TKIs gefitinib and erlotinib . In the United States , approximately 15 % of patients with adenocarcinoma of the lung harbor activating EGFR mutations . EGFR mutation testing is widespread at academic medical centers and in some locales in community practice . As of yet , there is no evidence of an overall survival ( OS ) benefit from selecting treatment based on performing this testing . RECENT DATA One large phase III trial ( the Iressa Pan-Asia Study [ IPASS ] trial ) , three smaller phase III r and omized controlled trials using progression-free survival as the primary end point , and one small phase III trial with OS as the primary end point , all involving first-line EGFR TKIs and chemotherapy doublets , form the basis of this PCO . PROVISIONAL CLINICAL OPINION On the basis of the results of five phase III r and omized controlled trials , patients with NSCLC who are being considered for first-line therapy with an EGFR TKI ( patients who have not previously received chemotherapy or an EGFR TKI ) should have their tumor tested for EGFR mutations to determine whether an EGFR TKI or chemotherapy is the appropriate first-line therapy . NOTE . ASCO 's provisional clinical opinions ( PCOs ) reflect expert consensus based on clinical evidence and literature available at the time they are written and are intended to assist physicians in clinical decision making and identify questions and setting s for further research . Because of the rapid flow of scientific information in oncology , new evidence may have emerged since the time a PCO was su bmi tted for publication . PCOs are not continually up date d and may not reflect the most recent evidence . PCOs can not account for individual variation among patients and can not be considered inclusive of all proper methods of care or exclusive of other treatments . It is the responsibility of the treating physician or other health care provider , relying on independent experience and knowledge of the patient , to determine the best course of treatment for the patient . Accordingly , adherence to any PCO is voluntary , with the ultimate determination regarding its application to be made by the physician in light of each patient 's individual circumstances . ASCO PCOs describe the use of procedures and therapies in clinical practice and can not be assumed to apply to the use of these interventions in the context of clinical trials . ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of ASCO 's PCOs , or for any errors or omissions The European Society of Thoracic Surgeons ( ESTS ) organized a workshop dealing with lymph node staging in non-small cell lung cancer . The objective of this workshop was to develop guidelines for definitions and the surgical procedures of intraoperative lymph node staging , and the pathologic evaluation of resected lymph nodes in patients with non-small cell lung cancer ( NSCLC ) . Relevant peer- review ed publications on the subjects , the experience of the participants , and the opinion of the ESTS members contributing on line , were used to reach a consensus . Systematic nodal dissection is recommended in all cases to ensure complete resection . Lobe-specific systematic nodal dissection is acceptable for peripheral squamous T1 tumors , if hilar and interlobar nodes are negative on frozen section studies ; it implies removal of , at least , three hilar and interlobar nodes and three mediastinal nodes from three stations in which the subcarinal is always included . Selected lymph node biopsies and sampling are justified to prove nodal involvement when resection is not possible . Pathologic evaluation includes all lymph nodes resected separately and those remaining in the lung specimen . Sections are done at the site of gross abnormalities . If macroscopic inspection does not detect any abnormal site , 2-mm slices of the nodes in the longitudinal plane are recommended . Routine search for micrometastases or isolated tumor cells in hematoxylin-eosin negative nodes would be desirable . R and omized controlled trials to evaluate adjuvant therapies for patients with these conditions are recommended . The adherence to these guidelines will st and ardize the intraoperative lymph node staging and pathologic evaluation , and improve pathologic staging , which will help decide on the best adjuvant therapy Purpose To up date the Potentially Curable Pancreatic Cancer : American Society of Clinical Oncology Clinical Practice Guideline published on May 31 , 2016 . The October 2016 up date focuses solely on new evidence that pertains to clinical question 4 of the guideline : What is the appropriate adjuvant regimen for patients with pancreatic cancer who have undergone an R0 or R1 resection of their primary tumor ? Methods The recently published results of a r and omized phase III study prompted an up date of this guideline . The high quality of the reported evidence and the potential for its clinical impact prompted the Expert Panel to revise one of the guideline recommendations . Results The ESPAC-4 study , a multicenter , international , open-label r and omized controlled phase III trial of adjuvant combination chemotherapy compared gemcitabine and capecitabine with gemcitabine monotherapy in 730 evaluable patients with resected pancreatic ductal adenocarcinoma .  Median overall survival was improved in the doublet arm to 28.0 months ( 95 % CI , 23.5 to 31.5 months ) versus 25.5 months ( 95 % CI , 22.7 to 27.9 months ) for gemcitabine alone ( hazard ratio , 0.82 ; 95 % CI , 0.68 to 0.98 ; P = .032 ) . Grade 3 and 4 adverse events were similar in both arms , although higher rates of h and -foot syndrome and diarrhea occurred in patients r and omly assigned to the doublet arm . Recommendations All patients with resected pancreatic cancer who did not receive preoperative therapy should be offered 6 months of adjuvant chemotherapy in the absence of medical or surgical contraindications . The doublet regimen of gemcitabine and capecitabine is preferred in the absence of concerns for toxicity or tolerance ; alternatively , monotherapy with gemcitabine or fluorouracil plus folinic acid can be offered . Adjuvant treatment should be initiated within 8 weeks of surgical resection , assuming complete recovery . The remaining recommendations from the original 2016 ASCO guideline are unchanged PURPOSE To provide evidence -based recommendations to oncologists and others for treatment of patients with locally advanced , unresectable pancreatic cancer . METHODS American Society of Clinical Oncology convened an Expert Panel of medical oncology , radiation oncology , surgical oncology , gastroenterology , palliative care , and advocacy experts and conducted a systematic review of the literature from January 2002 to June 2015 . Outcomes included overall survival , disease-free survival , progression-free survival , and adverse events . RESULTS Twenty-six r and omized controlled trials met the systematic review criteria . RECOMMENDATIONS A multiphase computed tomography scan of the chest , abdomen , and pelvis should be performed . Baseline performance status and comorbidity profile should be evaluated . The goals of care , patient preferences , psychological status , support systems , and symptoms should guide decisions for treatments . A palliative care referral should occur at first visit . Initial systemic chemotherapy ( 6 months ) with a combination regimen is recommended for most patients ( for some patients radiation therapy may be offered up front ) with Eastern Cooperative Oncology Group performance status 0 or 1 and a favorable comorbidity profile . There is no clear evidence to support one regimen over another . The gemcitabine-based combinations and treatments recommended in the metastatic setting ( eg , fluorouracil , leucovorin , irinotecan , and oxaliplatin and gemcitabine plus nanoparticle albumin-bound paclitaxel ) have not been evaluated in r and omized controlled trials involving locally advanced , unresectable pancreatic cancer . If there is local disease progression after induction chemotherapy , without metastasis , then radiation therapy or stereotactic body radiotherapy may be offered also with an Eastern Cooperative Oncology Group performance status ≤ 2 and an adequate comorbidity profile . If there is stable disease after 6 months of induction chemotherapy but unacceptable toxicities , radiation therapy may be offered as an alternative . Patients with disease progression should be offered treatment per the ASCO Metastatic Pancreatic Cancer Treatment Guideline . Follow-up visits every 3 to 4 months are recommended . Additional information is available at www.asco.org/ guidelines /LAPC and www.asco.org/ guidelines /MetPC and www.asco.org/ guidelines wiki AIMS Uncertainty remains regarding the optimal therapy for patients with stage II or III rectal cancer . Systematic review s and practice guidelines on preoperative and postoperative therapy for rectal cancer were published by the Gastrointestinal Cancer Disease Site Group in 2003 and 2000 , respectively . The systematic review s were up date d and revised and new recommendations for preoperative and postoperative therapy were developed based on the up date d body of evidence . The following research questions were addressed : After appropriate preoperative staging tests , should patients with resectable clinical stage II or III rectal cancer be offered preoperative radiotherapy ( with or without chemotherapy ) ? What is the role of postoperative radiotherapy and /or chemotherapy for patients with resected stage II or III rectal cancer who have not received preoperative radiotherapy  , in terms of improving survival and delaying local recurrence ? MATERIAL S AND METHODS The MEDLINE , EMBASE and Cochrane Library data bases , as well as meeting proceedings from the American Society of Clinical Oncology , were search ed for reports of r and omised controlled trials and meta-analyses comparing preoperative or postoperative therapy with surgery alone or other preoperative or postoperative therapy for stage II or III rectal cancer . The draft practice guideline and systematic review s were distributed through a mailed survey to 129 health care providers in Ontario for review . RESULTS Systematic review s on preoperative and postoperative therapy for rectal cancer were developed . On the basis of the evidence contained in these review s , the Gastrointestinal Cancer Disease Site Group drafted recommendations . Of the 33 practitioners who responded to the mailed survey , 97 % agreed with the draft recommendations as stated , 88 % agreed that the report should be approved as a practice guideline and 94 % indicated that they were likely to use the guideline in their own practice . CONCLUSIONS Preoperative chemoradiotherapy is preferred , compared with st and ard fractionation preoperative radiotherapy alone , to decrease local recurrence .  Preoperative chemoradiotherapy is also preferred , compared with a postoperative approach , to decrease local recurrence and adverse effects . For patients with relative contraindications to chemotherapy in the preoperative period , an acceptable alternative is preoperative radiotherapy alone followed by surgery .  Patients with resected stage II or III rectal cancer who have not received preoperative radiotherapy  should be offered postoperative therapy with concurrent chemoradiotherapy plus fluoropyrimidine-based chemotherapy OBJECTIVE To establish evidence -based recommendations for the molecular analysis of lung cancers that are required to guide EGFR- and ALK-directed therapies , addressing which patients and sample s should be tested , and when and how testing should be performed . PARTICIPANTS Three cochairs without conflicts of interest were selected , one from each of the 3 sponsoring professional societies : College of American Pathologists , International Association for the Study of Lung Cancer , and Association for Molecular Pathology . Writing and advisory panels were constituted from additional experts from these societies . EVIDENCE Three unbiased literature search es of electronic data bases were performed to capture published articles from January 2004 through February 2012 , yielding 1533 articles whose abstract s were screened to identify 521 pertinent articles that were then review ed in detail for their relevance to the recommendations . EVIDENCE was formally grade d for each recommendation . CONSENSUS PROCESS Initial recommendations were formulated by the cochairs and panel members at a public meeting . Each guideline section was assigned to at least 2 panelists . Drafts were circulated to the writing panel ( version 1 ) , advisory panel ( version 2 ) , and the public ( version 3 ) before su bmi ssion ( version 4 ) . CONCLUSIONS The 37 guideline items address 14 subjects , including 15 recommendations ( evidence grade A/B ) . The major recommendations are to use testing for EGFR mutations and ALK fusions to guide patient selection for therapy with an epidermal growth factor receptor ( EGFR ) or anaplastic lymphoma kinase ( ALK ) inhibitor , respectively , in all patients with advanced-stage adenocarcinoma , regardless of sex , race , smoking history , or other clinical risk factors , and to prioritize EGFR and ALK testing over other molecular predictive tests . As scientific discoveries and clinical practice outpace the completion of r and omized clinical trials , evidence -based guidelines developed by expert practitioners are vital for communicating emerging clinical st and ards . Already , new treatments targeting genetic alterations in other , less common driver oncogenes are being evaluated in lung cancer , and testing for these may be addressed in future versions of these guidelines Objective : To establish evidence -based recommendations for the molecular analysis of lung cancers that are that are required to guide EGFR- and ALK-directed therapies , addressing which patients and sample s should be tested , and when and how testing should be performed . Participants : Three cochairs without conflicts of interest were selected , one from each of the 3 sponsoring professional societies : College of American Pathologists , International Association for the Study of Lung Cancer , and Association for Molecular Pathology . Writing and advisory panels were constituted from additional experts from these societies . Evidence : Three unbiased literature search es of electronic data bases were performed to capture articles published published from January 2004 through February 2012 , yielding 1533 articles whose abstract s were screened to identify 521 pertinent articles that were then review ed in detail for their relevance to the recommendations . Evidence was formally grade d for each recommendation . Consensus Process : Initial recommendations were formulated by the cochairs and panel members at a public meeting . Each guideline section was assigned to at least 2 panelists . Drafts were circulated to the writing panel ( version 1 ) , advisory panel ( version 2 ) , and the public ( version 3 ) before su bmi ssion ( version 4 ) . Conclusions : The 37 guideline items address 14 subjects , including 15 recommendations ( evidence grade A/B ) . The major recommendations are to use testing for EGFR mutations and ALK fusions to guide patient selection for therapy with an epidermal growth factor receptor ( EGFR ) or anaplastic lymphoma kinase ( ALK ) inhibitor , respectively , in all patients with advanced-stage adenocarcinoma , regardless of sex , race , smoking history , or other clinical risk factors , and to prioritize EGFR and ALK testing over other molecular predictive tests . As scientific discoveries and clinical practice outpace the completion of r and omized clinical trials , evidence -based guidelines developed by expert practitioners are vital for communicating emerging clinical st and ards . Already , new treatments targeting genetic alterations in other , less common driver oncogenes are being evaluated in lung cancer , and testing for these may be addressed in future versions of these guidelines Purpose — The aim of this guideline is to provide a focused up date of the current recommendations for the  endovascular  treatment of  acute ischemic stroke . When there is overlap , the recommendations made here supersede those of previous guidelines . Methods — This focused up date analyzes results from 8 r and omized , clinical trials of endovascular treatment and other relevant data published since 2013 . It is not intended to be a complete literature review from the date of the previous guideline publication but rather to include pivotal new evidence that justifies changes in current recommendations . Members of the writing committee were appointed by the American Heart Association/American Stroke Association Stroke Council ’s Scientific Statement Oversight Committee and the American Heart Association/American Stroke Association Manuscript Oversight Committee . Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process . Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence . Prerelease review of the draft guideline was performed by 6 expert peer review ers and by the members of the Stroke Council Scientific Statement Oversight Committee and Stroke Council Leadership Committee . Results — Evidence -based guidelines are presented for the selection of patients with acute ischemic stroke for endovascular treatment , for the endovascular procedure , and for systems of care to facilitate endovascular treatment . Conclusions — Certain endovascular procedures have been demonstrated to provide clinical benefit in selected patients with acute ischemic stroke . Systems of care should be organized to facilitate the delivery of this care Purpose To provide current recommendations on the use of sentinel node biopsy ( SNB ) for patients with early-stage breast cancer . Methods PubMed and the Cochrane Library were search ed for r and omized controlled trials , systematic review s , meta-analyses , and clinical practice guidelines from 2012 through July 2016 . An Up date Panel review ed the identified abstract s. Results Of the eight publications identified and review ed , none prompted a change in the 2014 recommendations , which are reaffirmed by the up date d literature review . Conclusion Women without sentinel lymph node ( SLN ) metastases should not receive axillary lymph node dissection ( ALND ) . Women with one to two metastatic SLNs who are planning to undergo breast-conserving surgery with whole-breast radiotherapy should not undergo ALND ( in most cases ) . Women with SLN metastases who will undergo mastectomy should be offered ALND . These three recommendations are based on r and omized controlled trials . Women with operable breast cancer and multicentric tumors , with ductal carcinoma in situ , who will undergo mastectomy , who previously underwent breast and /or axillary surgery , or who received preoperative/neoadjuvant systemic therapy may be offered SNB .  Women who have large or locally advanced invasive breast cancer ( tumor size T3/T4 ) , inflammatory breast cancer , or ductal carcinoma in situ ( when breast-conserving surgery is planned ) or are pregnant should not undergo SNB Introduction : A significant proportion of lung cancer patients receive no anticancer treatment . This varies from 19 % in USA , 33 % in Australia , 37 % in Scotl and , and 50 % in Irel and . The aim of this study was to identify the reasons behind this . Methods : The Lung Cancer Multidisciplinary Meeting ( MDM ) in South-West Sydney prospect ively collects data on all patients presented . All new lung cancer patients presented between December 1 , 2005 , and December 31 , 2007 , were review ed . Patients were assigned optimal treatment based on evidence -based guidelines . Those patients in whom guidelines recommended no treatment ( GNT ) were compared with those whom the MDM recommended no treatment ( MNT ) and with those who actually received no treatment ( ANT ) . Results : There were 335 patients with a median age of 69 years . A total of 82 % had non-small cell lung cancer , 14 % had small cell lung cancer , and 4 % had no pathologic diagnosis . Eighty-five percent had locally advanced or metastatic disease .  GNT was recommended in 4 % ( n = 13 ) , MNT in 10 % ( n = 32 ) but ANT comprised 20 % ( n = 66 ) . The differences between GNT and MNT were mainly due to patient comorbidities and clinician decision , but the differences between MNT and ANT were due to patient preference and declining performance status . In multivariate analysis , older age , poorer Eastern Cooperative Oncology Group status , non-small cell lung cancer , and non-English language predicted for ANT . Conclusions : The proportion of patients with lung cancer receiving no treatment  is greater than that predicted by guidelines or recommended by the MDM but lower than that described in population -based studies suggesting that MDMs can improve treatment utilization in lung cancer
In the third-line setting , for patients who have not received erlotinib or gefitinib , treatment with erlotinib is recommended .
There are insufficient data to recommend routine third-line cytotoxic therapy .
Purpose To provide evidence -based recommendations to up date the American Society of Clinical Oncology guideline on systemic therapy for stage IV non – small-cell lung cancer ( NSCLC ) .
Results This guideline up date reflects changes in evidence since the previous guideline .