American Radium Society Appropriate Use Criteria for Unresectable Locally Advanced Non-Small Cell Lung Cancer

George Rodrigues; Kristin A Higgins; Andreas Rimner; Arya Amini; Joe Y Chang; Stephen G Chun; Jessica Donington; Martin J Edelman; Matthew A Gubens; Puneeth Iyengar; Benjamin Movsas; Matthew S Ning; Henry S Park; Andrea Wolf; Charles B Simone 2nd

doi:10.1001/jamaoncol.2024.0294

American Radium Society Appropriate Use Criteria for Unresectable Locally Advanced Non-Small Cell Lung Cancer

JAMA Oncol. 2024 Apr 11. doi: 10.1001/jamaoncol.2024.0294. Online ahead of print.

Authors

Affiliations

¹ Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada.
² Winship Cancer Institute, Emory University, Atlanta, Georgia.
³ Memorial Sloan Kettering Cancer Center, New York, New York.
⁴ City of Hope National Medical Center, Duarte, California.
⁵ The University of Texas, MD Anderson Cancer Center, Houston.
⁶ University of Chicago, Chicago, Illinois.
⁷ Fox Chase Comprehensive Cancer Center, Philadelphia, Pennsylvania.
⁸ Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco.
⁹ The University of Texas at Southwestern Medical Center, Dallas.
¹⁰ Henry Ford Cancer Institute, Detroit, Michigan.
¹¹ Yale School of Medicine, New Haven, Connecticut.
¹² Mount Sinai Health System, New York, New York.
¹³ New York Proton Center, New York, New York.

PMID: 38602670
DOI: 10.1001/jamaoncol.2024.0294

Abstract

Importance: The treatment of locally advanced non-small cell lung cancer (LA-NSCLC) has been informed by more than 5 decades of clinical trials and other relevant literature. However, controversies remain regarding the application of various radiation and systemic therapies in commonly encountered clinical scenarios.

Objective: To develop case-referenced consensus and evidence-based guidelines to inform clinical practice in unresectable LA-NSCLC.

Evidence review: The American Radium Society (ARS) Appropriate Use Criteria (AUC) Thoracic Committee guideline is an evidence-based consensus document assessing various clinical scenarios associated with LA-NSCLC. A systematic review of the literature with evidence ratings was conducted to inform the appropriateness of treatment recommendations by the ARS AUC Thoracic Committee for the management of unresectable LA-NSCLC.

Findings: Treatment appropriateness of a variety of LA-NSCLC scenarios was assessed by a consensus-based modified Delphi approach using a range of 3 points to 9 points to denote consensus agreement. Committee recommendations were vetted by the ARS AUC Executive Committee and a 2-week public comment period before official approval and adoption. Standard of care management of good prognosis LA-NSCLC consists of combined concurrent radical (60-70 Gy) platinum-based chemoradiation followed by consolidation durvalumab immunotherapy (for patients without progression). Planning and delivery of locally advanced lung cancer radiotherapy usually should be performed using intensity-modulated radiotherapy techniques. A variety of palliative and radical fractionation schedules are available to treat patients with poor performance and/or pulmonary status. The salvage therapy for a local recurrence after successful primary management is complex and likely requires both multidisciplinary input and shared decision-making with the patient.

Conclusions and relevance: Evidence-based guidance on the management of various unresectable LA-NSCLC scenarios is provided by the ARS AUC to optimize multidisciplinary patient care for this challenging patient population.