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 .
The role of pemetrexed as maintenance treatment in advanced NSCLC: a Phase III randomized trial
A r and omized Phase III trial tested the efficacy of pemetrexed as maintenance treatment in patients with advanced non-small-cell lung cancer ( NSCLC ) who were without progression after completing four cycles of first-line platinum-based chemotherapy .  The primary endpoint of the trial was progression-free survival ( PFS ) .  Pemetrexed was significantly better than placebo both in terms of PFS and overall survival . The study was not design ed as a direct comparison between ‘ early ’ and ‘ delayed ’ administration of pemetrexed because there was no m and atory cross-over in the control arm , in which less than 20 % of patients actually received pemetrexed as second-line . However , a relevant proportion of patients with advanced NSCLC , due to early death or clinical deterioration , will never be able to receive a second-line treatment after disease progression . At the end of first-line treatment , the immediate administration of a drug that has not been received before ( instead of adopting the ‘ wait and watch ’ approach based on stopping treatment until disease progression ) could be a positive strategy , allowing patients to receive early one more potentially active drug without an unacceptable increase in toxicity . This strategy should be discussed with patients . Prespecified analysis of efficacy by tumor histology showed a significant interaction between treatment and histology , with pemetrexed producing significant and clinical ly meaningful benefit compared to placebo in the non-squamous group , without efficacy in patients with squamous tumors
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 .