Chapter 7: Lung Cancer Contents Chapter 7: Lung Cancer... 1 Small Cell... 2 Good PS + Limited stage... 2 Cisplatin/etoposide... 2 Concurrent chemotherapy + XRT... 2 Good / Intermediate PS... 2 Carboplatin / Etoposide... 2 Poor PS... 3 Carboplatin... 3 Etoposide... 3 Second Line Chemotherapy... 4 Etoposide... 4 Carboplatin... 4 VAC... 5 Topotecan... 5 Non-Small Cell Lung Cancer... 6 Adjuvant... 6 Cisplatin/Vinorelbine... 6 Carboplatin/Vinorelbine... 7 Carboplatin/Vinorelbine (split dose)... 8 Locally advanced... 9 Concurrent Chemo/Radiotherapy Cisplatin/Vinorelbine Intravenous... 9 Advanced... 10 Cisplatin / Pemetrexed... 10 Cisplatin/Vinorelbine... 10 Carboplatin/Gemicitabine... 11 Carboplatin/Vinorelbine... 12 Vinorelbine... 12 Gemcitabine... 13 Gefitinib (Iressa )... 14 Erlotinib (Tarceva )... 14 Maintenance Pemetrexed... 15 Second line Chemotherapy... 16 Docetaxel... 16 Erlotinib (Tarceva )... 16 *Crizotinib... 17 *Pemetrexed... 18 Mesothelioma... 19 Cisplatin / Pemetrexed... 19 Carboplatin / Pemetrexed... 19 Issue Date: July 2014 Page 1 of 19 Issue No: 11.7.0
Small Cell Good PS + Limited stage Cisplatin/etoposide Cisplatin/etoposide Day 1 Cisplatin 70mg/m 2 IV infusion over 90 minutes Day 1 Etoposide 120mg/m 2 IV infusion over 60 minutes Day 2 Etoposide 240mg/m 2 Orally, in 2 divided doses Day 3 Etoposide 240mg/m 2 Orally, in 2 divided doses NB see cisplatin hydration recommendations Chapter 1 Laboratory investigations indicated Calculate creatinine clearance prior to each cycle and administer cisplatin according to guidelines Concurrent chemotherapy + XRT Cisplatin + etoposide as above with XRT commencing with cycle 2 Good / Intermediate PS Carboplatin / Etoposide Carboplatin/etoposide 4 to 6 cycles Day 1 Carboplatin AUC 5 IV infusion over 60 minutes Day 1 Etoposide phosphate 100mg/m 2 IV infusion over 15 minutes Day 2 Etoposide 200mg/m 2 Orally, in 2 divided doses Day 3 Etoposide 200mg/m 2 Orally, in 2 divided doses For patients unable to swallow oral etoposide capsules, daily intravenous etoposide phosphate can be administered (see separate electronic prescribing regimen) Issue Date: July 2014 Page 2 of 19 Issue No: 11.7.0
indicated Calculate or measure creatinine clearance prior to first cycle and before subsequent cycles if Poor PS Many poor PS patients will be too ill potentially to benefit from chemotherapy and symptomatic care will be the most appropriate option. For those judged to be fit enough the following may be considered: Carboplatin Carboplatin Day 1 Carboplatin AUC 4 to 5 IV infusion over 60 minutes Calculate or measure creatinine clearance prior to first cycle and before subsequent cycles if Etoposide Etoposide Upto 6 cycles Days 1 to 10 Etoposide 50mg BD Orally, twice a day for 10 days can be reduced to 7 days where indicated Calculate or measure creatinine clearance prior to first cycle and before subsequent cycles if Issue Date: July 2014 Page 3 of 19 Issue No: 11.7.0
Second Line Chemotherapy Etoposide Etoposide Upto 6 cycles Days 1 to 10 Etoposide 50mg BD Orally, twice a day for 10 days can be reduced to 7 days where indicated FBC prior to each cycle Normal FBC limits for administration apply Carboplatin Carboplatin Day 1 Carboplatin AUC 5 to 6 IV infusion over 60 minutes Calculate or measure creatinine clearance prior to first cycle and before subsequent cycles if FBC prior to each cycle Normal FBC limits for administration apply Issue Date: July 2014 Page 4 of 19 Issue No: 11.7.0
VAC VAC 4 to 6 cycles Day 1 Cyclophosphamide 750mg/m 2 IV bolus Day 1 Doxorubicin 50mg/m 2 IV bolus Day 1 Vincristine 1.4mg/m minutes (maximum dose 2mg) FBC prior to each cycle Normal FBC limits for administration apply Topotecan Topotecan Days 1 to 5 Topotecan 2.3mg/m 2 OD Orally, daily for 5 days Criteria PS 0-2 Cr Cl > 40ml/min CA125 prior to each cycle FBC prior to each dose Normal FBC limits for administration apply Issue Date: July 2014 Page 5 of 19 Issue No: 11.7.0
Non-Small Cell Lung Cancer Adjuvant Criteria Stage 1-3 completely resected PS 0-1 Cisplatin/Vinorelbine Cisplatin/Vinorelbine Intravenous 3 cycles Day 1 Cisplatin 80mg/m 2 IV infusion over 90 minutes Day 1 Vinorelbine 25mg/m Day 8 Vinorelbine 25mg/m OR Cisplatin/Vinorelbine Oral 3 cycles Day 1 Cisplatin 80mg/m 2 IV infusion over 90 minutes Day 1 Vinorelbine 60mg/m 2 Orally, single dose (maximum dose 120mg) Day 8 Vinorelbine 60mg/m 2 Orally, single dose (maximum dose 120mg) NB see cisplatin hydration recommendations Chapter 1 Laboratory investigations indicated Calculate creatinine clearance prior to each cycle and administer cisplatin according to guidelines Issue Date: July 2014 Page 6 of 19 Issue No: 11.7.0
Carboplatin/Vinorelbine Carboplatin/Vinorelbine Intravenous 3 cycles Day 1 Carboplatin AUC 5 IV infusion over 60 minutes Day 1 Vinorelbine 25mg/m Day 8 Vinorelbine 25mg/m OR Carboplatin/Vinorelbine Oral 3 cycles Day 1 Carboplatin AUC 5 IV infusion over 60 minutes Day 1 Vinorelbine 60mg/m 2 Orally, single dose (maximum dose 120mg) Day 8 Vinorelbine 60mg/m 2 Orally, single dose (maximum dose 120mg) Cycle length can be increased to 28 days if prolonged thrombocytopenia. indicated. Calculate or measure creatinine clearance prior to first cycle and before subsequent cycles if Issue Date: July 2014 Page 7 of 19 Issue No: 11.7.0
Carboplatin/Vinorelbine (split dose) Carboplatin/Vinorelbine Intravenous 3 cycles Day 1 Carboplatin AUC 2.5 IV infusion over 60 minutes Day 1 Vinorelbine 25mg/m Day 8 Carboplatin AUC 2.5 IV infusion over 60 minutes Day 8 Vinorelbine 25mg/m OR Carboplatin/Vinorelbine Oral 3 cycles Day 1 Carboplatin AUC 5 IV infusion over 60 minutes Day 1 Vinorelbine 60mg/m 2 Orally, single dose (maximum dose 120mg) Day 8 Carboplatin AUC 2.5 IV infusion over 60 minutes Day 8 Vinorelbine 60mg/m 2 Orally, single dose (maximum dose 120mg) Ciprofloxacin prophylaxis 500mg BD days 9 to 20 Cycle length can be increased to 28 days if prolonged thrombocytopenia. indicated Calculate or measure creatinine clearance prior to first cycle and before subsequent cycles if FBC prior to each cycle Normal FBC limits for administration apply Issue Date: July 2014 Page 8 of 19 Issue No: 11.7.0
Locally advanced Concurrent Chemo/Radiotherapy Cisplatin/Vinorelbine Intravenous Cisplatin/Vinorelbine Intravenous and concurrent radiotherapy One course only 4 weeks Fractions 1 to 4 Cisplatin 20mg/m 2 daily IV infusion over 60 minutes, daily Fraction 1 Vinorelbine 15mg/m minutes Fraction 6 Vinorelbine 15mg/m minutes Fraction 15 Vinorelbine 15mg/m minutes Fractions 16 to 19 Cisplatin 20mg/m 2 daily IV infusion over 60 minutes, daily Fraction 20 Vinorelbine 15mg/m minutes Note: these are chemotherapy treatments associated with fractions of radiotherapy, and therefore treatment should ideally commence on a Monday. If it commences on a different day of the week then consider the dates carefully when prescribing. Followed at 4-6 weeks by: Cisplatin/Vinorelbine Intravenous 2 cycles Day 1 Cisplatin 80mg/m 2 IV infusion over 90 minutes Day 1 Vinorelbine 25mg/m Day 8 Vinorelbine 25mg/m NB see cisplatin hydration recommendations Chapter 1 Laboratory investigations indicated Calculate creatinine clearance prior to each cycle and administer cisplatin according to guidelines Issue Date: July 2014 Page 9 of 19 Issue No: 11.7.0
Advanced Cisplatin / Pemetrexed Cisplatin/Pemetrexed Dexamethasone 4mg BD Orally for 3 days, commencing 24 hours prior to pemetrexed Day 1 Pemetrexed 500mg/m 2 IV infusion over 10 minutes Day 1 Cisplatin 75mg/m 2 IV infusion over 90 minutes NB see cisplatin hydration recommendations Chapter 1 Vitamin B12 injection IM 1 week prior to start + every 9 weeks until completion Folic acid 400micrograms daily oral during treatment, and for at least 3 weeks post treatment Stop all NSAIDS during chemotherapy Criteria: Non-squamous carcinomas PS 0-1 Cisplatin/Vinorelbine Cisplatin/Vinorelbine Intravenous Day 1 Cisplatin 80mg/m 2 IV infusion over 90 minutes Day 1 Vinorelbine 25mg/m Day 8 Vinorelbine 25mg/m Issue Date: July 2014 Page 10 of 19 Issue No: 11.7.0
OR Cisplatin/Vinorelbine Oral Day 1 Cisplatin 80mg/m 2 IV infusion over 90 minutes Day 1 Vinorelbine 60mg/m 2 Orally, single dose (maximum dose 120mg) Day 8 Vinorelbine 60mg/m 2 Orally, single dose (maximum dose 120mg) NB see cisplatin hydration recommendations see Chapter 1 Laboratory investigations indicated Calculate creatinine clearance prior to each cycle and administer cisplatin according to guidelines Carboplatin/Gemicitabine Carboplatin/Gemcitabine Day 1 Carboplatin AUC 5 IV infusion over 60 minutes Day 1 Gemcitabine 1250mg/m 2 IV infusion over 30 minutes Day 8 Gemcitabine 1250mg/m 2 IV infusion over 30 minutes Cycle interval can be increased to 28 days if indicated NB: transaminases may rise during treatment Calculate or measure creatinine clearance prior to first cycle and before subsequent cycles if Issue Date: July 2014 Page 11 of 19 Issue No: 11.7.0
Carboplatin/Vinorelbine Carboplatin/Vinorelbine Intravenous Day 1 Carboplatin AUC 4 to 5 IV infusion over 60 minutes Day 1 Vinorelbine 25mg/m Day 8 Vinorelbine 25mg/m OR Carboplatin/Vinorelbine Oral Day 1 Carboplatin AUC 4 to 5 IV infusion over 60 minutes Day 1 Vinorelbine 60mg/m 2 Orally, single dose (maximum dose 120mg) Day 8 Vinorelbine 60mg/m 2 Orally, single dose (maximum dose 120mg) Cycle length can be increased to 28 days if indicated Calculate or measure creatinine clearance prior to first cycle and before subsequent cycles if Vinorelbine Vinorelbine Intravenous Day 1 Vinorelbine 25 to 30mg/m Day 8 Vinorelbine 25 to 30mg/m OR Issue Date: July 2014 Page 12 of 19 Issue No: 11.7.0
Vinorelbine Oral 2 Orally, single dose (maximum doses 120mg Day 1 Vinorelbine 60 to 80mg/m and 160mg ie capped at 2m 2 ) 2 Orally, single dose (maximum doses 120mg Day 8 Vinorelbine 60 to 80mg/m and 160mg ie capped at 2m 2 ) Criteria: No prior chemotherapy PS 0-2 FBC prior to each cycle Normal FBC limits for administration apply Gemcitabine Gemcitabine Every 28 Days 6 cycles Day 1 Gemcitabine 1000mg/m 2 IV infusion over 30 minutes Day 8 Gemcitabine 1000mg/m 2 IV infusion over 30 minutes Day 15 Gemcitabine 1000mg/m 2 IV infusion over 30 minutes Day 15 can be omitted in patients with poorer PS or thrombocytopenia indicated NB: transaminases may rise during treatment Issue Date: July 2014 Page 13 of 19 Issue No: 11.7.0
Gefitinib (Iressa ) Gefitinib Continuous Until disease progression Daily Gefitinib 250mg daily Orally, daily Criteria Locally advanced / metastatic NSCLC, first line therapy EGFR mutation positive Erlotinib (Tarceva ) Erlotinib Continuous Until disease progression Daily Erlotinib 150mg daily Orally, daily Criteria EGFR mutation positive First line FBC prior to each cycle Normal FBC limits for administration apply Issue Date: July 2014 Page 14 of 19 Issue No: 11.7.0
Maintenance Pemetrexed Maintenance pemetrexed is available through the normal funding mechanism for patients who fulfil the criteria set out by NICE and who did not receive pemetrexed as part of first line therapy. For those patients who received pemetrexed as part of first line therapy and who fulfil the criteria funding is available via the CDF Pemetrexed maintenance Until disease progression Dexamethasone 4mg BD Orally for 3 days, commencing 24 hours prior to docetaxel Day 1 Pemetrexed 500mg/m 2 IV infusion over 10 minutes Vitamin B12 injection IM 1 week prior to start + every 9 weeks until completion Folic acid 400 micrograms daily oral during treatment, and for at least 3 weeks post treatment Stop all NSAIDS during chemotherapy Criteria: Non-squamous carcinomas PS 0-1 CR/PR/SD following first line chemotherapy First line chemotherapy with Platinum + vinorelbine/paclitaxel/gemcitabine/docetaxel *NB available via the Cancer Drugs fund CDF Criteria (as at 14 May 2014) The maintenance treatment of advanced non-squamous non-small cell lung cancer where all the following criteria are met: 1. Application made by and first cycle of systemic anti-cancer therapy to be prescribed by a consultant specialist specifically trained and accredited in the use of systemic anti-cancer therapy 2. Non-squamous non-small cell lung cancer 3. As maintenance therapy following 1 st line chemotherapy with cisplatin and pemetrexed not progressing after of such chemotherapy 4. PS 0 or 1 at time to commence maintenance pemetrexed Note: the evidence for the use of maintenance pemetrexed following induction chemotherapy with the combination of pemetrexed and carboplatin has not been established and is therefore not approved. Issue Date: July 2014 Page 15 of 19 Issue No: 11.7.0
Second line Chemotherapy Docetaxel Docetaxel Dexamethasone 8mg BD Orally for 3 days, commencing 24 hours before docetaxel Day 1 Docetaxel 75mg/m 2 IV infusion over 60 minutes Criteria PS 0-1 Previous response or stable disease to platinum based chemotherapy Progression free interval following platinum based chemotherapy > 6m FBC prior to each cycle Normal FBC limits for administration apply Erlotinib (Tarceva ) Erlotinib Continuous Until disease progression Daily Erlotinib 150mg daily Orally, daily Criteria Progression following chemotherapy for advanced disease Fit to receive docetaxel as second line therapy No prior anti EGFR therapy Issue Date: July 2014 Page 16 of 19 Issue No: 11.7.0
*Crizotinib Crizotinib Continuous Until disease progression Daily Crizotinib 250mg BD Orally, twice daily Dose reduction is to 200mg BD *NB available via the Cancer Drugs fund CDF Criteria (as at 14 May 2014) The treatment of ALK +ve advanced or metastatic non-small cell lung cancer where all the following criteria are met: 1. Application made by and first cycle of systemic anti-cancer therapy to be prescribed by a consultant specialist specifically trained and accredited in the use of systemic anti-cancer therapy 2. ALK +ve advanced or metastatic non-small cell lung cancer 3. 2 nd or subsequent line treatment post 1 st line combination chemotherapy Issue Date: July 2014 Page 17 of 19 Issue No: 11.7.0
*Pemetrexed Pemetrexed single agent Until disease progression Dexamethasone 4mg BD Orally for 3 days, commencing 24 hours before pemetrexed Day 1 Pemetrexed 500mg/m 2 IV infusion over 10 minutes Vitamin B12 1mg injection IM 1 week prior to start + every 9 weeks until completion Folic acid 400micrograms daily oral during treatment, and for at least 3 weeks post treatment Stop all NSAIDS during chemotherapy *NB available via the Cancer Drugs fund CDF Criteria (as at 14 May 2014) The second line treatment of advanced non-squamous non-small cell lung cancer where all the following criteria are met: 1. Application made by and first cycle of systemic anti-cancer therapy to be prescribed by a consultant specialist specifically trained and accredited in the use of systemic anti-cancer therapy 2. Advanced or metastatic non-squamous non-small cell lung cancer 3. Used as 2 nd line treatment 4. No previous pemetrexed treatment Issue Date: July 2014 Page 18 of 19 Issue No: 11.7.0
Mesothelioma Cisplatin / Pemetrexed Cisplatin/Pemetrexed Upto 6 cycles Dexamethasone 4mg BD Orally for 5 days, commencing 24 hours before pemetrexed Day 1 Pemetrexed 500mg/m 2 IV infusion over 10 minutes Day 1 Cisplatin 75mg/m 2 IV infusion over 90 minutes NB see cisplatin hydration recommendations in chapter one Vitamin B12 injection IM 1 week prior to start + every 9 weeks until completion Folic acid 400micrograms daily oral during treatment and for at least 3 weeks post treatment Stop all NSAIDS during chemotherapy Carboplatin / Pemetrexed Carboplatin/Pemetrexed Upto 6 cycles Dexamethasone 4mg BD Orally for 5 days, commencing 24 hours before pemetrexed Day 1 Pemetrexed 500mg/m 2 IV infusion over 10 minutes Day 1 Carboplatin AUC 4 to 5 IV infusion over 60 minutes Vitamin B12 injection IM 1 week prior to start + every 9 weeks until completion Folic acid 400micrograms daily oral during treatment Stop all NSAIDS during chemotherapy Issue Date: July 2014 Page 19 of 19 Issue No: 11.7.0