Clinical Stage IA

Positive mediastinal nodes

Negative mediastinal nodes

Treat as stage IIIA / IIIB

Positive Margins?

Surveillance

RT

Operable

Inoperable

Definitive RT or SRS

Non-Small Cell Lung Cancer (NSCLC)

Updated: 2017-08-18

NO

YES

Re-resection (preferred)

Regimens are being updated, and are not yet complete.

COMMENTS from Pathway Team

Treatment Pathways Index

NSCLC COME HOME Regimens

Stage IB, IIA, IIB (Node Negative)

Inoperable

SRS

Operable

Concurrent RT, + one of:
CH LNG 1: Cisplatin
CH LNG 2: Carboplatin + pemetrexed
CH LNG 3: Cisplatin + pemetrexed
CH LNG 5: Paclitaxel + carboplatin

T3N0, T3N1 chest wall /
mediastinal / hilar invasion

Surgical Margins

T < 4 cm

Surveillance

T >= 4 cm

Re-resection (preferred)
- OR -
RT alone

Sequential chemoradiation:
CH LNG 4: Paclitaxel + carboplatin
CH LNG 5: Paclitaxel + carboplatin (weekly)
CH LNG 6: Cisplatin + vinblastine
CH LNG 14: Paclitaxel + carboplatin
Followed by thoracic RT

Chemotherapy:
CH LNG 4: Paclitaxel + carboplatin
CH LNG 5: Paclitaxel + carboplatin (weekly)
CH LNG 6: Cisplatin + vinblastine
CH LNG 14: Paclitaxel + carboplatin

Non-Small Cell Lung Cancer (NSCLC)

Updated: 2017-08-18

Negative

Positive

Resection

Regimens are being updated, and are not yet complete.

COMMENTS from Pathway Team

Treatment Pathways Index

NSCLC COME HOME Regimens

Stage IIIA

Concurrent RT, + one of:
CH LNG 1: Cisplatin
CH LNG 2: Carboplatin + pemetrexed
CH LNG 3: Cisplatin + pemetrexed
CH LNG 5: Paclitaxel + carboplatin

Re-Stage

CH LNG 3: Pemetrexed + cisplatin
CH LNG 4/5: Paclitaxel + carboplatin
CH LNG 7/8: Cisplatin + vinorelbine
CH LNG 9: Cisplatin + gemcitabine
CH LNG 10: Cisplatin + docetaxel
CH LNG 11: Paclitaxel
CH LNG 12: Docetaxel + carboplatin

Progressive or persistent disease

Treat as Metastatic

Stable

Surveillance

Non-Small Cell Lung Cancer (NSCLC)

Updated: 2017-08-18

RT and/or Surgery

Regimens are being updated, and are not yet complete.

COMMENTS from Pathway Team

Treatment Pathways Index

NSCLC COME HOME Regimens

Operable

Inoperable

Stage IIIB

Staging

Progressive or persistent disease

Treat as Metastatic

Stable

Surveillance

Non-Small Cell Lung Cancer (NSCLC)

Updated: 2017-08-18

Regimens are being updated, and are not yet complete.

COMMENTS from Pathway Team

Treatment Pathways Index

NSCLC COME HOME Regimens

Concurrent RT, + one of:
CH LNG 1: Cisplatin
CH LNG 2: Carboplatin + pemetrexed
CH LNG 3: Cisplatin + pemetrexed
CH LNG 5: Paclitaxel + carboplatin

Metastatic Disease
First Line Therapy
Non-Squamous

EGFR/ALK Negative

EGFR Positive

CH LNG 20: Crizotinib

Progression or intolerance

2nd line Therapy
CLICK

Test for T790M

Progression

Progression

Progression

CH LNG 21: Ceritinib

CH LNG : Nivolumab
- OR -
CH LNG: Pembrolizumab
(PDL-1 > 50%)

CH LNG : Nivolumab
- OR -
If PDL-1 > 50%:
CH LNG: Pembrolizumab

CH LNG: Osimertinib

CH LNG 18: Erlotinib
CH LNG 19: Afatinib

ALK / ROS-1 Positive

CH LNG 2: Carboplatin +
pemetrexed
CH LNG 28: Paclitaxel +
carboplatin +/-
bevacizumab

Maintenance therapy:
CH LNG 16: Pemetrexed
CH LNG 17: Bevacizumab
OR
Observation

Progression

Non-Small Cell Lung Cancer (NSCLC)

Updated: 2017-08-18

Regimens are being updated, and are not yet complete.

COMMENTS from Pathway Team

Treatment Pathways Index

NSCLC COME HOME Regimens

Positive

Negative

Metastatic Disease
First Line Therapy
Squamous

PS 0-2

Progression

PS 3-4

CH LNG 4/5: Carboplatin + paclitaxel
CH LNG 9: Cisplatin + gemcitabine +/- necitumumab
CH LNG 10: Cisplatin + docetaxel
CH LNG 12: Carboplatin + docetaxel
CH LNG 22: Carboplatin + gemcitabine
CH LNG 24: Docetaxel

CH LNG 30: Nivolumab
CH LNG 31: Pembrolizumab (PD-L1 positive only)
– OR –
Best Supportive Care

CH LNG 24: Docetaxel
CH LNG 26: Gemcitabine CH LNG 27: Vinorelbine
CH LNG 30: Nivolumab
CH LNG 31: Pembrolizumab (PD-L1 positive only)
CH LNG 32: Atezolizumab
– OR –
Best Supportive Care

Non-Small Cell Lung Cancer (NSCLC)

Updated: 2017-08-18

Regimens are being updated, and are not yet complete.

COMMENTS from Pathway Team

Treatment Pathways Index

NSCLC COME HOME Regimens

Metastatic Disesse
Second Line Therapy

CH LNG 3: Cisplatin + Pemetrexed
CH LNG 24: Docetaxel
CH LNG 25: Pemetrexed (nonsquamous)
CH LNG 26: Gemcitabine
CH LNG 27: Vinorelbine
CH LNG 28: Paclitaxel + Carboplatin + Bevacizumab
CH LNG 30: Nivolumab
CH LNG 31: Pembrolizumab (PD-L1 positive only)
CH LNG 32: Atezolizumab

Progression

PS 0-2

PS 3-4

Non-Small Cell Lung Cancer (NSCLC)

Updated: 2017-08-18

Best Supportive Care

Regimens are being updated, and are not yet complete.

COMMENTS from Pathway Team

Treatment Pathways Index

NSCLC COME HOME Regimens