1102 www.thelancet.com/oncology Vol 10 November 2009 Review First-line systemic treatment of advanced stage non-small-cell lung cancer in Asia: consensus statement from the Asian Oncology Summit 2009 Ross A Soo, Benjamin O Anderson, Byoung Chul Cho, Chih-Hsin Yang, Meilin Liao, Wan-Teck Lim, Peter Goldstraw, Tony S Mok Non-small-cell lung cancer (NSCLC) is an increasing global challenge, especially in low-income countries. Most guidelines for the management of advanced-stage NSCLC have limited effect in countries with resource constraints. Following a systematic literature search, we present an overview of the management of advanced-stage NSCLC in the first-line setting, discuss resources required for systemic therapy, and provide treatment recommendations stratified to four resources levels. Treatment guidelines appropriate for different resource levels offer a realistic approach to management of advanced-stage NSCLC, by recognising the limitations of a particular health-care system. Although there are many barriers to cancer control in low-resource countries, these can be overcome by using measures that are culturally appropriate, economically feasible, and evidence-based. Initiatives include strategic planning, tobacco control, training of health-care workers, access to therapeutic agents, acquisition of information, public education, and alliances with established institutions and international organisations. Introduction Cancer is a major health challenge worldwide. In 2007, there were an estimated 12 million new cases of cancer and 7·6 million cancer deaths. In terms of incidence, lung cancer is one of the most common malignancies in the world, accounting for 1·52 million cases or 12% of all newly diagnosed cancers. Because of its poor prognosis, lung cancer was also the most common cause of cancer deaths in 2007, causing 1·3 million deaths annually. 1 Many Asian countries are still in the early period of the tobacco-smoking epidemic, and the number of lung-cancer deaths in these countries is projected to increase over the next few decades. It is estimated that by 2030, 70% of tobacco-related deaths will occur in developing countries. 2 High quality evidence-based guidelines for the treatment of advanced stage non-small-cell lung cancer (NSCLC) are available, 3–5 but an often overlooked issue is that such guidelines do not consider the differences in the availability of resources and thus have limited applicability in low-income and middle-income countries (LMCs). 6 Given the diversity of infrastructure and economies in Asian countries, and with more therapeutic options becoming available for advanced-stage NSCLC, there is a need to provide resource-sensitive recommendations. Resource levels are defined in this paper according to a 4-tiered system (basic, limited, enhanced, and maximum) as described previously by the Breast Global Health Initiative (webpanel 1). 7 The objectives of this paper are to review the first line systemic treatment of patients with advanced stage NSCLC, to describe resources required for administration of systemic therapy, and to provide treatment recommendations based on resource availability. These recommendations were formulated in a lung-cancer consensus session at the Asian Oncology Summit in Singapore, April 5, 2009. Further details on the origin and running of the consensus workshop can be found in an accompanying commentary. First-line systemic therapy Multiple individual randomised studies and several meta-analyses have shown a survival benefit for systemic chemotherapy compared with best supportive care in patients with good performance status. 8 Alkylating-agent- based chemotherapy, however, was associated with a detrimental effect on survival. 8 In a recent updated meta-analysis, the 1-year survival was 29% for chemotherapy and 20% for best supportive care (HR 0·77, 95% CI 0·71–0·83). 9 Studies of platinum-based regimens and newer agents reported either no change or an improvement in quality of life. Single-agent versus combination drug regimens As a doublet regimen, older (or second-generation) chemotherapy regimens consist mainly of a combination Lancet Oncol 2009; 10: 1102–10 See Reflection and Reaction page 1029 This is the fourth in a series of six consensus statements Department of Haematology- Oncology, National University Hospital, and Cancer Science Institute of Singapore, National University of Singapore, Singapore (R A Soo FRACP); Department of Surgery, University of Washington, Seattle, WA, USA (Prof B O Anderson MD); Division of Medical Oncology, Yonsei Cancer Center, Seoul, South Korea (B C Cho MD); Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan (Prof C-H Yang MD); Shanghai Chest Hospital, Shanghai, China (Prof M Liao MD); Department of Medical Oncology, National Cancer Center, Singapore (W-T Lim MB); Department of Thoracic Surgery, Royal Brompton Hospital, London, UK (Prof P Goldstraw FRCS); and Department of Clinical Oncology, Chinese University of Hong Kong, China (Prof T S Mok MD) Correspondence to: Dr Ross Soo, Department of Haematology-Oncology, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074 ross_soo@nuhs.edu.sg See Online for webpanel 1 Figure: Coloured X-ray of the left lung of a patient with lung cancer Zephyr/Science Photo Library