Original Guideline: February 1996
There was considerable discussion amongst the Lung Disease Site Group (DSG) about the ultimate benefit of treating patients with stage IV non-small cell lung cancer (NSCLC) with chemotherapy. Although the evidence presented in this report does not suggest a long-term (i.e., beyond 1-year) survival benefit for patients receiving chemotherapy, it does suggest there is a clear benefit in the form of a small prolongation in survival (median survival and proportion of patients alive at one year) and in the reduction of disease-related symptoms. Ultimately, it was felt that the treatment a patient receives will vary depending on the goal of the treatment and the outcome that is clinically important for the individual patient.
For patients who value prolonged survival (of the expected magnitude) as the primary goal of their treatment, there is strong evidence that cisplatin-based chemotherapy is the treatment of choice. However, this does not preclude the use of newer chemotherapeutic agents such as vinorelbine (see the Ontario Cancer Treatment Practice Guidelines Initiative's practice guideline Use of vinorelbine in non-small cell lung cancer). For patients who value improved quality of life as the primary goal of their treatment, the evidence is less strong that chemotherapy is the treatment of choice. However, it may still be a reasonable treatment option to offer chemotherapy in this scenario as it may reduce symptoms; this may subsequently improve quality of life.
A critical aspect of this recommendation and the deliberations of the group was that physicians should enter into a discussion with their patients about the risks and benefits of all treatment options, including the option of chemotherapy (where it is medically appropriate). When patients are fully informed of their options, the values they hold and choices they make about their treatment should be respected.
The Lung Disease Site Group agreed that the magnitude of the survival prolongation was small and, as such, would not preclude the study of investigational agents in previously untreated patients with stage IV disease. Further investigations that incorporate formal quality of life evaluations are also needed. Finally, as the role of immediate versus delayed treatment with chemotherapy is not clear, clinical trials addressing this issue are warranted.
The cost to the health care system of implementing a recommendation for chemotherapy treatment in stage IV disease was also deliberated. It was recognized that there are currently a variety of chemotherapy regimens that are used as "standard" for which there is only evidence from cohort studies of efficacy. However, these regimens produce response rates and median survival times similar to regimens studied in randomized trials and found superior to best supportive care only.
Update: January 2003
The information above remains current.