Stage III Non-Small Cell Lung Cancer
Diagnosis
Evaluation and Staging
Recommendation 1.1
For patients with suspected stage III NSCLC, an evaluation to exclude metastatic disease should include, at a minimum: history and physical exam and computed tomography (CT) scan of chest and upper abdomen (with contrast, unless contraindicated).
(IC, B, L, S)Recommendation 1.2
Following evaluation with CT scan as per Recommendation 1.1, fluorodeoxyglucose positron emission tomography (FDG PET) with CT scan and brain imaging should be performed.
(EB, B, H, S)Recommendation 1.3
Recommendation 1.4
For patients who require pathologic assessment of lymph node status, endoscopic techniques should be offered as the initial staging modality.
(EB, B, M, S)Recommendation 1.5
For patients who require pathologic assessment of lymph node status but for whom endoscopic staging is either unavailable or inconclusive, surgical confirmation of mediastinal stage should be performed.
(EB, B, M, S)Recommendation 1.6
For patients who have suspected or confirmed stage III NSCLC, multidisciplinary discussion should occur prior to the initiation of any treatment plan.
(EB, B, M, S)Good Practice Point
Biopsy should generally be performed from the site that would establish the highest stage when feasible. Potential tissue yield for pathologic analysis and molecular sequencing should also be considered.
(, , , )Surgery
Recommendation 2.1
For patients with stage IIIA (N2) NSCLC, induction therapy followed by surgery (with or without adjuvant therapy) may be offered if all of the following conditions are met:
- A complete resection (R0) of the primary tumor and involved lymph nodes is deemed possible.
- N3 lymph nodes are deemed to be not involved by multidisciplinary consensus.
- Perioperative (90-day) mortality is expected to be low (≤5%).
Recommendation 2.2
For selected patients with T4N0 disease (by size or extension), surgical resection may be offered if medically and surgically feasible following multidisciplinary review.
(EB, B, M, W)Good Practice Points
Patients with stage III NSCLC generally should not be excluded from consideration for surgery by nonsurgical physicians.
(, , , )Presence of oncogenic driver alterations, available therapies, and patient characteristics should be taken into account.
(, , , )Patients and providers should consider enrollment on clinical trials when appropriate.
(, , , )Treatment
Neoadjuvant Therapy
Recommendation 3.1
Patients who are planned for a multimodality approach incorporating surgery as defined in Recommendation 2.1 should receive systemic neoadjuvant therapy.
(EB, B, M, S)Recommendation 3.2
Recommendation 3.3
For patients with resectable superior sulcus disease, neoadjuvant concurrent chemoradiation should be administered.
(EB, B, M, S)Adjuvant Therapy
Recommendation 4.1
Patients with resected stage III NSCLC who did not receive neoadjuvant systemic therapy should be offered adjuvant platinum based chemotherapy.
(EB, B, H, S)Recommendation 4.2
Patients with resected stage III NSCLC with EGFR exon 19 deletion or exon 21 L858R mutation should be offered adjuvant osimertinib after platinum-based chemotherapy.
(EB, B, H, S)Recommendation 4.3
For patients with completely resected NSCLC with mediastinal N2 involvement without extracapsular extension who have received neoadjuvant or adjuvant platinum-based chemotherapy, postoperative radiation therapy should not be routinely offered.
(EB, B/H, M, W)Unresectable Disease
Recommendation 5.1
Patients with stage III NSCLC who are medically or surgically inoperable and good performance status should be offered concurrent instead of sequential chemotherapy and radiation therapy.
(EB, B, H, S)Recommendation 5.2
Concurrent chemotherapy delivered with radiation therapy for definitive treatment of stage III NSCLC should include a platinum-based doublet, preferably cisplatin plus etoposide, carboplatin plus paclitaxel, cisplatin plus pemetrexed (non-squamous only), or cisplatin plus vinorelbine.
(EB, B, H, S)Recommendation 5.3
Recommendation 5.4
Patients with stage III NSCLC receiving concurrent chemoradiation should be treated to 60 Gy.
(EB, B, H, S)Recommendation 5.5
Recommendation 5.6
Patients with stage III NSCLC receiving definitive radiation without chemotherapy in standard fractionation may be considered for radiation dose escalation and for modest hypofractionation from 2.15–4 Gy per fraction.
(EB, B, L, W)Recommendation 5.7
Patients with stage III NSCLC receiving concurrent chemoradiation without disease progression during the initial therapy should be offered consolidation durvalumab for up to 12 months.
(EB, B, H, S)Qualifying statement: There is insufficient evidence to alter the recommendation for consolidation durvalumab following concurrent chemo-radiation for molecularly defined subgroups (namely patients with an oncogenic driver alteration or those with low/no expression of programmed death-ligand 1 [PD-L1]).
Recommendation 5.8
(Update): Patients with unresectable stage III NSCLC with an EGFR exon 19 deletion or exon 21 L858R mutation may be offered consolidation osimertinib after definitive chemoradiotherapya.
(, , M, S)a Platinum based chemotherapy and thoracic radiation given concurrently or sequentially.
Recommendation Grading
Abbreviations
- CT: Computed Tomography
- EGFR: Epidermal Growth Factor Receptor
- FDG PET: Fluorodeoxyglucose-positron Emission Tomography
- Gy: Gray
- NSCLC: Non-small Cell Lung Cancer
- PD-L1: Programmed Death Ligand 1
Disclaimer
Overview
Title
Management of Stage III Non-Small Cell Lung Cancer
Authoring Organization
American Society of Clinical Oncology
Publication Month/Year
July 23, 2024
Last Updated Month/Year
November 7, 2024
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
US
Document Objectives
The purpose of this guideline is to provide evidence-based recommendations to practicing clinicians on management of patients with stage III non–small-cell lung cancer (NSCLC), and to help clinicians involved in the diagnosis and treatment of lung cancer accurately confirm the presence of stage III non–small-cell lung cancer (NSCLC) and offer the most appropriate treatments.
Target Patient Population
Patients with stage III NSCLC
Target Provider Population
Medical oncologists, radiation oncologists, thoracic surgeons, pulmonologists, pathologists, radiologists, primary care physicians, nurse practitioners, physician assistants, pharmacists, nurses, and other providers
PICO Questions
For patients with stage III NSCLC, does prescribing osimertinib as a consolidation therapy versus a placebo group have increased adverse events?
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Outpatient, Radiology services
Intended Users
Nurse, nurse practitioner, physician, physician assistant, radiology technologist
Scope
Assessment and screening, Treatment, Management
Diseases/Conditions (MeSH)
D002289 - Carcinoma, Non-Small-Cell Lung, D017024 - Chemotherapy, Adjuvant, D020360 - Neoadjuvant Therapy, D059248 - Chemoradiotherapy, D059186 - Chemoradiotherapy, Adjuvant
Keywords
lung cancer, non-small cell lung cancer, non-small-cell lung carcinoma (NSCLC), NSCLC, Stage III, stage IIIA
Source Citation
Daly ME, Singh N, Ismalia N, et al. Management of Stage III NSCLC: ASCO Guideline Rapid Recommendation Update. J Clin Oncol. 2024 July 23. doi:10.1200/JCO.24.01324
Singh N, Daly ME, Ismaila N, et al. Management of Stage III NSCLC: ASCO Guideline Rapid Recommendation Update. J Clin Oncol. 2023 July 20. doi:10.1200/JCO.23.01261
Daly ME, Singh N, Ismaila N, et al. Management of Stage III NSCLC: ASCO Guideline. J Clin Oncol. 2021 Dec 22. doi:10.1200/JCO.21.02528