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 .
Randomized phase III trial of maintenance bevacizumab with or without pemetrexed after first-line induction with bevacizumab, cisplatin, and pemetrexed in advanced nonsquamous non-small-cell lung cancer: AVAPERL (MO22089).
PURPOSE Maintenance therapy is associated with improved survival in patients with non-small-cell lung cancer ( NSCLC ) , but few studies have compared active agents in this setting . AVAPERL evaluated the safety and efficacy of bevacizumab with or without pemetrexed as continuation maintenance treatment . PATIENTS AND METHODS Patients with advanced nonsquamous NSCLC received first-line  bevacizumab 7.5 mg/kg , cisplatin 75 mg/m(2 ) , and pemetrexed 500 mg/m(2 ) once every 3 weeks for four cycles . Those achieving response or stable disease were r and omly assigned at a ratio of 1:1 to maintenance bevacizumab 7.5 mg/kg or bevacizumab 7.5 mg/kg plus pemetrexed 500 mg/m(2 ) once every 3 weeks until disease progression or unacceptable toxicity . The primary end point was progression-free survival ( PFS ) after r and om assignment . RESULTS In total , 376 patients received induction treatment , 71.9 % achieved disease control , and 67.3 % were r and omly assigned to maintenance therapy , with 125 and 128 receiving single-agent bevacizumab and bevacizumab plus pemetrexed treatment , respectively . At a median follow-up of 8.1 months , PFS from r and om assignment was significantly improved in the bevacizumab plus pemetrexed arm ( median , 3.7 v 7.4 months ; hazard ratio , 0.48 ; 95 % CI , 0.35 to 0.66 ; P < .001 ) per a stratified model . The PFS benefit extended across age , performance status , smoking history , and induction response ( stable disease v partial response ) subgroups . Any grade , grade ≥ 3 , and serious adverse events occurred more often with bevacizumab plus pemetrexed maintenance . No new safety signals were observed . CONCLUSION In an unselected population of patients with nonsquamous NSCLC who had achieved  disease control  with platinum-based chemotherapy plus bevacizumab , bevacizumab plus pemetrexed maintenance was associated with a significant PFS benefit compared with bevacizumab alone . The combination was well tolerated
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 .