La prise en charge en première ligne de traitement des CBNPC de stade IV était jusqu’à présent guidée par les recommandations publiées par l’ASCO en 2003. Cependant, en cinq ans, de nouvelles molécules sont venues enrichir nos possibilités thérapeutiques, et de nouvelles notions bousculent nos standards. Depuis 2007, une nouvelle notion est apparue : le choix de la chimiothérapie en fonction de l’histologie, soit selon des critères de tolérance avec l’AMM du bevacizumab, soit selon des critères d’efficacité avec l’AMM du pemetrexed en 2008.

Until recently, first-line chemotherapy for advanced non-small cell lung cancer (NSCLC) was based on ASCO guidelines. Since several years, first-line chemotherapy is a platin-based doublet for patients with a good performans status. For elderly or unfit patients, a single-drug chemotherapy or a combination without cisplatin was recommended. The association of an anti-angiogenic therapy, bevacizumab, with carboplatin-paclitaxel or cisplatin-gemcitabine regimens improves progression-free survival for patients with non-epidermoid tumors. The combination of cisplatin and pemetrexed is better in terms of survival than cisplatine-gemcitabine in these tumors. The choice of treatment according to histology is becoming a new concept. Another is maintenance therapy. The main objective is to reduce duration of platin-based chemotherapy while improving quality of life and progression-free survival. This concept is ongoing validation. The combination of cetuximab with platin-chemotherapy improves survival for all histologic types. We should integrate this new approach among other available treatments. First-line therapy for advanced NSCLC is changing. In the future, first-line therapy will be chosen according to clinical features and biomarkers such as gene mutations of EGFR.