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Annals of Oncology

doi:10.1093/annonc/mdr313

special article 1st ESMO Consensus Conference in lung cancer;Lugano 2010:Small-cell lung cancer

R.Stahel 1,*,N.Thatcher 2,M.Fru ¨h 3,C.Le Pe ′choux 4,P.E.Postmus 5,J.B.Sorensen 6,E.Felip 7&Panel members

1Department of Oncology,University Hospital Zurich,Zurich,Switzerland;2Department of Medical Oncology,Christie Hospital,Manchester,UK;3Department of Oncology and Hematology,Cantonal Hospital St Gallen,St Gallen,Switzerland;4Department of Radiation Oncology,Institut Gustave Roussy,Villejuif,France;5Department of Pulmonology,Vrije Universiteit Medical Centre,Amsterdam,The Netherlands;6Department of Oncology,Finsen Centre/National University Hospital,Copenhagen,Denmark;7Department of Medical Oncology,Vall d’Hebron University Hospital,Barcelona,Spain

Received 8April 2011;revised 11May 2011;accepted 27May 2011

The 1st ESMO Consensus Conference on lung cancer was held in Lugano,Switzerland on 21st and 22nd May 2010with

the participation of a multidisciplinary panel of leading professionals in pathology and molecular diagnostics and medical,

surgical and radiation oncology.Before the conference,the expert panel prepared clinically relevant questions

concerning ?ve areas as follows:early and locally advanced non-small-cell lung cancer (NSCLC),?rst-line metastatic

NSCLC,second-/third-line NSCLC,NSCLC pathology and molecular testing,and small-cell lung cancer (SCLC)to be

addressed through discussion at the Consensus Conference.All relevant scienti?c literature for each question was

reviewed in advance.During the Consensus Conference,the panel developed recommendations for each speci?c

question.The consensus agreement in SCLC is reported in this article.The recommendations detailed here are based on

an expert consensus after careful review of published data.All participants have approved this ?nal update.

Key words:Consensus,ESMO,SCLC

Lugano 2010:Background to the ESMO Consensus Conference In 2009,European Society for Medical Oncology (ESMO)decided to update the ESMO clinical recommendations in lung cancer through a consensus process addressing ?ve speci?c areas:1-Early and locally advanced non-small-cell lung cancer (NSCLC)2-NSCLC pathology and molecular testing 3-First-line metastatic NSCLC 4-Second-/third-line NSCLC 5-Small-cell lung cancer (SCLC)Five working groups were appointed,each comprised six to eight participants with multidisciplinary involvement and led by a chair,and with the assistance of one expert in methodological aspects.A total of 39experts were involved in this consensus process (see Panel members listed in the Appendix).The 1st ESMO Consensus Conference on Lung Cancer was held in May 2010in Lugano.Before the conference,each group identi?ed a number of clinically relevant questions suitable for consensus discussion and provided the available literature.At the Conference,in ?ve parallel sessions,each group discussed and reached agreement on the questions

previously chosen.Decisions were made using studies

published in peer review journals.If no relevant published data were identi?ed,expert opinions were considered.The consideration of abstracts was at the discretion of the groups.All relevant scienti?c literature,as identi?ed by the experts,was considered.A systematic literature search was not carried out.The recommendations from each group

were then presented to all the experts and discussed,and

a general consensus was reached.The ‘Infectious Diseases Society of American-United States Public Health Service Grading System’was used (shown in Tables 1and 2)for level of evidence and strength of recommendation for each question raised [1].

The consensus in SCLC is detailed here.SCLC remains an

important focus for treatment and research.The SCLC ESMO

Guidelines 2010[2]were endorsed and should be read in

conjunction with these additional comments on speci?c patient situations.Table 3provides a summary of panel recommendations.The ?nal recommendations listed here have been approved by all participants.

s p e c i a l a

r t i c l e *Correspondence to :Prof.R.Stahel,Department of Oncology,Ramistrasse 100,University Hospital Zurich,8091Zurich,Switzerland.Tel:+4144-634-2871;Fax:+4144-

634-2872;E-mail:rolf.stahel@usz.ch See Appendix for members of the Panel.aThe Author 2011.Published by Oxford University Press on behalf of the European Society for Medical Oncology.

Annals of Oncology Advance Access published July 4, 2011 at Kaohsiung Medical University Library on July 25, https://www.wendangku.net/doc/e213536395.html, Downloaded from

STAGING ISSUES 1.What is limited stage?Limited stage should be based on the TNM (tumour–node–metastasis)7classi?cation i.e.T1-4N0-3M0[3].In the new IASLC (International Association for the Study of Lung Cancer)staging system,the largest difference in patient outcomes was observed in patients with N1versus N2disease (19versus 14months median survival,hazard ratio =1.40,P =0.0001)[4].Furthermore,tumour size was of particular prognostic relevance in patients with N0/N1.Recommendation 1:The new TNM 7staging system for NSCLC is to be adopted for SCLC.Strength of recommendation:A Level of evidence:I https://www.wendangku.net/doc/e213536395.html,e of FDG–PET Several studies have suggested that the old distinction between limited and extensive stage can be improved with

positron

Table 1.Level of evidence [1]

Table 2.Strength of recommendation [1]Table 3.Summary of recommendations Recommendations

Staging issues

Recommendation 1The new TNM 7staging system

for NSCLC is to be adopted for SCLC

Recommendation 2The use of PET is not based on

randomised trials and treatment

decisions should not be based on PET ?ndings alone.PET ?ndings which could modify treatment

decisions should be pathologically con?rmed Recommendation 3For a solitary extrathoracic metastasis

based on initial staging

examinations,pathologic proof is

often not feasible and may delay

treatment.Depending on the

clinical situation,early response

evaluation to initial chemotherapy

can be more appropriate in

deciding whether a solitary

metastasis is likely to be metastatic

or not.If bone is the sole metastatic site,magnetic resonance imaging may be preferred to more invasive

procedures

Treatment issues

First-line treatment

Recommendation 4In patients with clinical T1-2N0-1stage that are potential surgical patients,mediastinal node

exploration should be carried out.

Surgery may be indicated in

patients with no mediastinal

involvement,and resection should

be followed by chemotherapy.

Postoperative radiotherapy should

be considered for pathologic N1

and unforeseen N2disease

Recommendation 5First-line chemotherapy should be

offered to patients with metastatic

SCLC and PS 0–2.It may be

considered in selected cases in PS 3–4

Recommendation 6Limited-stage patients with good PS should be considered for concomitant chemoradiotherapy,taking into account the feasibility of radiation treatment plan and good planning target volume coverage while maintaining normal tissue dose constraints Recommendation 7Thoracic radiotherapy given either concomitantly or sequentially is

currently not recommended in

patients with distant metastases

that have responded to

chemotherapy special article Annals of Oncology 2|Stahel et al. at Kaohsiung Medical University Library on July 25, 2011

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emission tomography (PET)and that it has a potential role

in adapting target volume for radiotherapy [5–8].However,

histological con?rmation of discordant PET ?ndings is not

routinely carried out and the current studies have severe

limitations as regards pathologic correlation.

Recommendation 2:The use of PET is not based on

randomised trials and treatment decisions should not be based

on PET ?ndings alone.PET ?ndings,which could modify

treatment decisions,should be pathologically con?rmed.

Strength of recommendation:C

Level of evidence:III

3.Single M1b

Recommendation 3.1:For a solitary extrathoracic metastasis

based on initial staging examinations,pathologic proof is often

not feasible and may delay treatment.Depending on the clinical

situation,early response evaluation to initial chemotherapy can be more appropriate in deciding whether a solitary metastasis is

likely to be metastatic or not.

Strength of recommendation:C

Level of evidence:V

Recommendation 3.2:If bone is the sole metastatic site,

magnetic resonance imaging may be preferred to more invasive

procedures.

Strength of recommendation:B

Level of evidence:V

TREATMENT ISSUES:FIRST-LINE

TREATMENT

The ?gure shows a treatment algorithm using the new TNM 7

staging classi?cation.

4.Should surgery be considered for any speci?c

subgroup?

Several retrospective reports on surgically treated early SCLC

patients indicated relatively favourable outcomes of this

approach if there was no mediastinal lymph node involvement

[9–11].Randomised clinical trials addressing the role of surgery

and adjuvant chemotherapy versus combined

chemoradiotherapy in node-negative SCLC are lacking.The

panel believes that these retrospective data are consistent

enough to consider surgical approach in selected and

adequately staged SCLC patients.

Recommendation 4:In patients with clinical T1-2N0-1stage

who are potential surgical patients,mediastinal node exploration

should be carried out.Surgery may be indicated in patients with

no mediastinal involvement;resection should be followed by

chemotherapy.Postoperative radiotherapy should be considered

for pathologic N1and unforeseen N2disease.

Strength of recommendation:C

Level of evidence:V

5.What is the treatment of choice for

chemotherapy-naive patients with M1disease?

Platinum/etoposide chemotherapy is a standard as outlined

in the 2010ESMO recommendations [2].A recent meta-

Table 3.(Continued )Recommendations Recommendation 8In patients with brain involvement as the only metastatic site responding to chemotherapy,concomitant chemotherapy with thoracic radiotherapy is currently not recommended Recommendation 9PCI is recommended for patients with tumour response.Response should be determined by

a restaging CT scan Recommendation 10PCI in patients who are 65years or

older,requires to balance the

bene?t and risk of possible neurocognitive impairment to be considered Follow-up issues Recommendation 11Subsequent follow-up should be at 2–3months in non-progressing patients at the end of initial treatment and response determination.The actual timing depends on patient circumstances and availability of further treatment.Imaging with CT is preferable Treatment issues

Second-line treatment and

beyond Recommendation 12Sensitive disease:retreat with the same regimen that induced their initial response,usually reinduction with platinum/

etoposide Recommendation 13Resistant disease:either oral or i.v.topotecan is recommended for

selected patients having resistant relapse,i.e.not amenable to reinduction with ?rst-line treatment Recommendation 14Refractory disease and beyond second-line treatment:selected patients with good PS may bene?t from further treatment with a chemotherapy agent not previously used Recommendation 15Patients,not previously treated with thoracic radiotherapy with a symptomatic recurrence in the mediastinum,such as superior cava vein obstruction or obstructed major airway,may bene?t from thoracic radiotherapy Recommendation 16Local brain re-irradiation,which

may include stereotactic

radiotherapy,may be considered in selected patients Annals of Oncology special article

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analysis has suggested equivalence between irinotecan/ platinum and etoposide/platinum in extensive-stage patients and a further study in Caucasian population has suggested that irinotecan/cisplatin is not inferior to etoposide/cisplatin [12,13].

Recommendation5:First-line chemotherapy should be offered to patients with metastatic SCLC and performance status(PS)of zero to two(scenario1).It may be considered in selected cases in PS of three to four(scenario2). Strength of recommendation:scenario1:A;scenario2:C Level of evidence:scenario1:I;scenario2:V

6.Patient eligibility for early concurrent thoracic radiotherapy on cycle1or2

Patients with good PS are eligible for early concurrent thoracic radiotherapy in cycle1or2[2,14].Computed tomography(CT)-based three-dimensional conformal radiotherapy is https://www.wendangku.net/doc/e213536395.html,e of FDG–PET for target volume de?nition is being evaluated.There is no standard dose that may vary between45Gy(twice daily)and55–70Gy (once daily).Trials exploring the optimal dose and fractionation are ongoing.There are no speci?c recommendations for SCLC in terms of normal tissue constraints.Based on NSCLC data,both V20corresponding to the percentage of normal lung parenchyma receiving20Gy and the mean lung dose(MLD)should be recorded as they correlate with the risk of radiation pneumonitis[15].As target volumes may be large,a V20level of35%–40%or an MLD of 20–23Gy can be considered acceptable,but some patients ( 10%–15%)may develop severe radiation-induced toxicity [16].Recent studies have explored an involved-?eld approach without elective irradiation[17–19].Furthermore,in subgroup analysis of prospective trials,elderly patients with good PS seem to have similar outcomes to younger patients and age does not appear to impact on ef?cacy[20–22]. Toxicity,particularly haematological may be greater among the elderly.

Recommendation6:Limited-stage patients with good PS should be considered for concomitant chemoradiotherapy, taking into account the feasibility of radiation treatment plan and good planning target volume coverage while maintaining normal tissue dose constraints.

Strength of recommendation:A

Level of evidence:II

7.Other special metastatic situations

A single-centre?ve-arm randomised study indicated a5.4%5-year improvement in a subgroup of patients with metastatic disease who had either a complete or partial response within the thorax and complete remission of distant disease after initial chemotherapy with the use concomitant thoracic radiotherapy and chemotherapy versus chemotherapy alone [23].The hypothesis generated by this subgroup analysis is being addressed in a phase III multicentre study. Recommendation7:Thoracic radiotherapy given either concomitantly or sequentially is currently not recommended in patients with distant metastases that have responded to chemotherapy.

Strength of recommendation:C

Level of evidence:II

8.Brain metastases as the only metastatic site When the brain is the only documented metastatic site of disease,the use of whole-brain radiotherapy and thoracic radiotherapy in addition to chemotherapy may lead to more favourable results,based on a small retrospective study of30 patients[24].Data from a prospective study are needed to support the observation.

Recommendation8:In patients with brain involvement as the only metastatic site responding to chemotherapy,concomitant chemotherapy with thoracic radiotherapy is currently not recommended.

Strength of recommendation:C

Level of evidence:

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9.Which patients should be considered for prophylactic cranial irradiation?

Prophylactic cranial irradiation(PCI)is recommended at the end of initial therapy for patients with a tumour response and no contraindications for this procedure.It is important to de?ne tumour response for consideration of PCI[25–27].Although chest X-ray was most often used in the older trials included in the meta-analysis[25],the panel believes the restaging should be done with the use of CT scan.The imaging should be carried out at3–4weeks after the end of initial treatment,as at this stage the determination of tumour response is not yet hampered by the radiotherapy-induced?brosis.

Recommendation9:PCI is recommended for patients with tumour response.Response should be determined by

a restaging CT scan.

Strength of recommendation:A

Level of evidence:I

10.Role of PCI in older patients

The mean age in the PCI meta-analysis was59with25%of patients being65years or older.However,age older than60–65 is a risk factor for neurocognitive impairment[28,29]. Recommendation10:PCI in older patients,65years and older,requires to balance the bene?t and risk of possible neurocognitive impairment to be considered.

Strength of recommendation:B

Level of evidence:II

FOLLOW-UP ISSUES

11.What is the optimal follow-up?

SCLC is likely to relapse or progress after initial treatment and second-line treatment improves survival in good PS patients [30].Detecting a relapse or progression before deterioration of PS is therefore a reasonable approach.Long-term survivors may be at risk of second lung cancer that should be histologically con?rmed.

Recommendation11:Subsequent follow-up should be at2–3 months in non-progressing patients at the end of initial treatment and response determination.The actual timing depends on patient circumstances and availability of further treatment.Imaging with CT is preferable.

Strength of recommendation:C

Level of evidence:V

TREATMENT ISSUES:SECOND-LINE TREATMENT AND BEYOND

The majority of patients with SCLC experience relapse after their initial treatment,with a median survival of2–3months without second-line therapy.Although second-line therapy may induce responses in 10%–40%of patients,these are usually short-lived,and the median survival rarely exceeds6months [31].

Three categories of disease have been described in the literature regarding the response to initial therapy and the duration of response:sensitive,resistant,and refractory.‘Sensitive’refers to patients who have had a tumour response lasting90days or longer.‘Resistant’refers to patients who have recurred within90 days of completing therapy.‘Refractory’refers to patients with tumours that never responded to?rst-line therapy or to those who progressed during?rst-line therapy[30].

12.Sensitive disease

Patients having sensitive disease relapsing>90days after?rst-line treatment may bene?t from retreatment. Recommendation12:Retreat with the same regimen that induced their initial response,usually reinduction with platinum/etoposide.

Strength of recommendation:C

Level of evidence:V

13.Resistant disease

In patients having resistant disease,topotecan improved overall survival compared with best supportive care[31].No statistically signi?cant difference in median survival was found in

a randomised trial comparing topotecan with combination chemotherapy although topotecan caused less toxicity[32]. There is no evidence that combination chemotherapy is superior to single-agent regimens.Both oral and i.v.topotecan had similar ef?cacy but with slight differences in toxicity[33,34]. Recommendation13:Either oral or i.v.topotecan is recommended for selected patients having resistant relapse,i.e. not amenable to reinduction with?rst-line treatment. Strength of recommendation:B

Level of evidence:II

14.Refractory disease and beyond second-line treatment

A poor PS,early relapse(within6weeks)following?rst-line treatment[30],and refractory disease are adverse prognostic factors for response and for survival.There is currently no standard second-line chemotherapy regimen for patients who fail to respond to initial treatment(refractory disease)or who relapse shortly after completion of?rst-line treatment(resistant disease with early relapse)in contrast to resistant disease having late relapse.Active agents from phase II trials include amrubicin,topotecan,irinotecan,paclitaxel,docetaxel, gemcitabine,ifosfamide,and oral etoposide(if etoposide not included in?rst-line treatment).No drugs have so far been approved by the Food and Drug Administration or the European Medicines Agency for this indication.

Recommendation14:Selected patients with good PS may bene?t from further treatment with a chemotherapy agent not previously used.

Strength of recommendation:B

Level of evidence:III

15.Symptomatic local recurrence in mediastinum Recommendation15:Patients,not previously treated with thoracic radiotherapy with a symptomatic recurrence in the mediastinum,such as superior caval vein obstruction or

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obstructed major airway,may bene?t from thoracic radiotherapy[35–37].

Strength of recommendation:C

Level of evidence:IV

16.Repeat cranial radiotherapy

For recurrence in the brain after PCI or whole-brain radiotherapy, repeat radiotherapy may be useful in carefully selected patients if no systemic treatment options are available[38–42]. Recommendation16:Local brain re-irradiation,which may include stereotactic radiotherapy,may be considered in selected patients. Strength of recommendation:C

Level of evidence:V

FUTURE

Several trials could in?uence treatment options in the near future.These include:

The CONVERT and CALGB30610trials addressing the dose and fractionation issues of concurrent thoracic chemoradiotherapy in limited-stage SCLC.

The ongoing individual data meta-analysis of early versus late concurrent thoracic radiotherapy and chemotherapy.

The CREST Dutch trial addressing the role of thoracic radiotherapy in patients with restricted metastatic disease. Studies addressing the ef?cacy of novel systemic treatments, including amrubicin and targeted agents.

acknowledgements

The authors thank Marianne Paesmans of Institut Jules Bordet, Universite′Libre de Bruxelles,Brussels,Belgium for her great support in methodological aspects during the consensus process.The authors also thank Claire Bramley and all ESMO staff for their support throughout the whole consensus process.

Appendix

Members of the panel

Prof.L.Crino,D.Gandara,and M.Reck,were unable to attend the conference,but had a major impact on the preparatory work for the conference and on the?nal manuscript.

Paul Baas,Department of Thoracic Oncology,The Netherlands Cancer Institute,Amsterdam,The Netherlands;Benjamin Villejuif,Department de Medicine,Institut Gustave Roussy, Villejuif,France;Fiona Blackhall,Department of Medical Oncology,The Christie NHS Foundation Trust,Manchester, UK;Federico Cappuzzo,Department of Medical Oncology, Ospedale Civile di Livorno,Livorno,Italy;Fortunato Ciardiello,Division of Medical Oncology,Department of Experimental and Clinical Medicine and Surgery F.Magrassi and https://www.wendangku.net/doc/e213536395.html,nzara,Second University of Naples,Naples,Italy; Lucio Crino`,Department of Oncology,Hospital Santa Maria della Misericordia,Sant Andrea delle Fratte,Perugia,Italy; Filippo de Marinis,Thoracic Oncology Unit I,San Camillo Forlanini Hospitals,Rome,Italy;Rafal Dziadziuszko, Department of Oncology and Radiotherapy,Medical University of Gdansk,Gdansk,Poland;Wilfried Eberhardt,Department of Medicine,West German Tumor Centre,University Hospital of University Duisburg-Essen,Essen,Germany;Corinne Faivre-Finn,Department of Clinical Oncology,The Christie NHS Foundation Trust,Manchester,UK;Enriqueta Felip,Oncology Department,Vall d’Hebron University Hospital,Barcelona, Spain;Martin Fru¨h,Department of Oncology/Hematology, Cantonal Hospital St Gallen,Switzerland;David Gandara, Division of Hematology/Oncology,University of California Davis Cancer Center,Sacramento,CA,USA;Cesare Gridelli, Division of Medical Oncology,San Giuseppe Moscati Hospital, Avellino,Italy;Glenwood Goss,The Ottawa Hospital Cancer Centre,Ottawa,ON,Canada;Pasi A.Ja¨nne,Dana Farber Cancer Institute and Harvard Medical School,Boston,MA, USA;Keith Kerr,Department of Pathology,Aberdeen University Medical School,Aberdeen Royal In?rmary, Foresterhill,Aberdeen,UK;Siow Ming Lee,University College London Hospital and UCL Cancer Institute,London, Department of Oncology,University College Hospital,London, UK;Cecile Le Pe′choux,Radiotherapy Department,Institut Gustave Roussy,Villejuif,France;Christian Manegold,Medical Faculty Mannheim,University of Heidelberg,University Medical Center Mannheim,Germany;Keith McGregor,The European Society for Medical Oncology,Lugano,Switzerland; Tony Mok,Department of Clinical Oncology,The Chinese University of Hong Kong,Hong Kong,China;Kenneth

O’Byrne,St James’s Hospital,Dublin,Ireland;Luis Paz-Ares, University Hospital—Virgen del Rocio,Seville,Spain;Robert Pirker,Medical University of Vienna,Vienna,Austria;Pieter E. Postmus,Vrije Universiteit Medical Center,Amsterdam,The Netherlands;Martin Reck,Hospital Grosshansdorf,Department of Thoracic Oncology,Grosshansdorf,Germany;Rafael Rosell, Catalan Institute of Oncology,Hospital Germans Trias i Pujol, Badalona,Spain;Suresh Senan,Department of Radiation Oncology,VU University Medical Center,Amsterdam,The Netherlands;Egbert F.Smit,Department of Pulmonary Diseases, Vrije Unversiteit Medical Centre,Amsterdam,The Netherlands; Jens B.Sorensen,Department of Oncology,Finsen Centre, National University Hospital,Copenhagen,Denmark;Rolf A. Stahel,University Hospital Zurich,Zurich,Switzerland;Miquel Taron,Medical Oncology Service,Institut Catala d’Oncologia, Hospital Germans Trias i Pujol,Badalona,Barcelona,Spain; Nicholas Thatcher,Department of Medical Oncology,Christie Hospital NHS Trust,Manchester,UK;Jan P.van Meerbeeck, Thoracic Oncology,Ghent University Hospital,Gent,Belgium; Paul Van Schil,Department of Thoracic and Vascular Surgery, Antwerp University Hospital,Belgium;Johan Vansteenkiste, Respiratory Oncology Unit,University Hospital Gasthuisberg, Leuven,Belgium;Alain Vergnenegre,Service de Pathologie Respiratoire,CHU,Limoges,France;Walter Weder,Division

of Thoracic Surgery,University Hospital Zurich,Zurich, Switzerland.

disclosure

Rafal Dziadziuszko(speakers’bureau and advisory board role—Roche,GSK,AstraZeneca);Wilfried Eberhardt(speakers’

special article Annals of Oncology

6|Stahel et al. at Kaohsiung Medical University Library on July 25, https://www.wendangku.net/doc/e213536395.html, Downloaded from

bureau and advisory board role—AstraZeneca,GSK,Merck Serono,Roche,Novartis,sano?-aventis,ImClone,Bristol-Myers Squibb,Eli Lilly,Merck USA,Bayer Schering,OSI,

P?zer);Enriqueta Felip(speakers’bureau and advisory board role—Eli Lilly,AstraZeneca,GSK,Merck Serono,Roche, Boehringer Ingelheim);David Gandara(consulting—Amgen, AstraZeneca,Biodesix,Boehringer-Ingelheim,Bristol-Myers Squibb,ImClone,GSK,Genentech,Lilly,Merck,Novartis,

P?zer,Sano?-aventis);Cesare Gridelli(speakers’bureau and advisory board role—Roche,AstraZeneca,Eli Lilly,Merck Serono);Glenwood D Goss(research funding—Roche Canada);Pasi Ja¨nne(consulting—P?zer,AstraZeneca,Roche, Genentech,Boehringer Ingelheim;stock ownership—Gatekeeper Pharmaceuticals;other—royalties from patent in EGFR mutation);Tony Mok(honoraria& consulting—AstraZeneca,Roche,P?zer;honoraria—Eli Lilly, Merck;consulting—Bristol-Myers Squibb,Eisai);Kenneth O’Byrne(advisory board role and research funding—Merck Serono,Roche,AstraZeneca);Robert Pirker(speakers’bureau and advisory board role—AstraZeneca,Eli Lilly,Merck Serono, Roche,Pierre Fabre;advisory board role—Boehringer Ingelheim,Bristol-Myers Squibb,P?zer);Martin Reck (speakers’bureau&consulting—Hoffmann-La Roche,Lilly, Merck,AstraZeneca;Consulting—Bristol-Myers Squibb); Suresh Senan(research funding—Eli Lilly);Nicholas Thatcher (speakers’bureau and advisory board role—AstraZeneca, Roche,Lilly,Boehringer,Bristol-Myers Squibb);Johan Vansteenkiste(research funding—Eli Lilly,Amgen, AstraZeneca)

The following panel members have declared no con?icts

of interest:Paul Baas,Benjamin Besse,Fiona Blackhall, Federico Cappuzzo,Fortunato Ciardiello,Filippo de Marinis, Corinne Faivre-Finn,Martin Fru¨h,Keith M Kerr,

Siow Ming Lee,Cecile Le Pechoux,Christian Manegold,Keith McGregor,Luis Paz-Ares,Pieter E.Postmus,Rafael Rosell, Egbert F.Smit,Jens B.Sorensen,Rolf Stahel,Miguel Taron,Jan P.van Meerbeeck,Paul Van Schil,Alain Vergnenegre,Walter Weder.

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