2026 CSCO Update: A Comprehensive Look at the Management of Non - Small Cell Lung Cancer Diagnosis and Treatment

From the perspective of the 2026 update of the guidelines of the Chinese Society of Clinical Oncology (CSCO), when examining the entire management process of non - small cell lung cancer diagnosis and treatment, it can be observed that lung cancer treatment has entered the “precision era”. The core essence of this era is to select the most effective treatment plan based on the genetic characteristics (molecular typing) of the tumor. The entire diagnosis - treatment process is closely interlinked and is primarily divided into two stages: precise detection and precise treatment.

The first stage: Comprehensive and accurate molecular detection

The core foundation of precision therapy lies in attaining precise diagnosis. By leveraging advanced molecular detection technologies, it is possible to accurately identify, localize, and characterize the key gene variants that drive the onset of lung cancer, promote its development, and govern its evolution. These technologies offer a crucial basis for a profound understanding of the molecular mechanisms of lung cancer, thereby laying a solid scientific foundation for the subsequent formulation and implementation of highly personalized treatment options.

I．Core Testing Principles

1. All non - small cell lung cancers with adenocarcinoma components should be routinely tested for driver genes such as EGFR, ALK, and ROS1.

2. Priority should be given to acquiring tumor tissue or cytological samples for testing. This is because the blood testing technology is not yet fully developed in terms of detecting ALK and ROS1 fusion genes.

3.It is advisable to employ established multi - gene synchronous detection techniques (e.g., PCR or NGS) to enhance the efficiency of specimen utilization.

II．Test points for patients with different stages

1. Early (Stage I - III) patients who can undergo surgery

(1)If the postoperative diagnosis is stage IB, II, or III non - squamous cell carcinoma, EGFR mutation testing is necessary to determine the requirement for adjuvant targeted therapy.

(2)For postoperative phase II and III patients, PD - L1 expression testing is required to guide the formulation of adjuvant immunotherapy.

(3) For patients with stage IB, II, and III after surgery, ALK fusion testing is also required.

2. Inoperable patients with locally advanced and advanced stage (Stage III - IV)

(1) Must - test items (recommended for Level I):

For non - squamous cell carcinoma tissues, a comprehensive gene profiling covering EGFR, ALK, ROS1, RET, NTRK fusion, MET 14 exon jump mutation, MET amplification, BRAF V600 mutation, KRAS mutation, HER2 mutation, etc., should be conducted. Simultaneously, tissue specimens must be utilized for PD - L1 expression detection.

(2) Important supplementary tests (recommended for Level II):

These include HER2 amplification, MET protein overexpression detection, etc.

(3) Special circumstances:

For patients who are non - smokers, diagnosed with squamous cell carcinoma after a small biopsy, or have mixed synthetic components, driver gene testing is also recommended.

III．Clinical Significance of Key Gene Variants

1. EGFR Mutation

In the patient population of our country, the incidence rate is relatively high, particularly among the non - smoking population.

2.  ALK Fusion

The incidence rate in the overall population is approximately 3% - 7%. In patients with EGFR/KRAS wild - type adenocarcinoma, the incidence rate can reach as high as 30% - 42%. In the group of young patients (age < 51 years old), the incidence of this gene fusion is higher.

3. Other Targets

For instance, ROS1 fusion, RET rearrangement, BRAF V600, NTRK, MET, KRAS G12C, HER2, etc., there are corresponding targeted drugs. A positive test result indicates that the patient may benefit from the corresponding targeted therapy.

The second stage: individualized treatment based on typing

Based on the aforementioned detailed test results, the latest version of the 2026 treatment guidelines has meticulously formulated a distinct, well - defined, and highly actionable personalized treatment pathway for diverse patient groups. The categorization of each specific treatment recommendation in the guidelines is strictly grounded in the scientific level of the highest - quality clinical research evidence available. Moreover, it comprehensively takes into account the actual clinical value and patient benefits of these treatment options in the real - world context, thereby ensuring the scientific, rigorous, and practical nature of the recommendations.

I．Treatment Progress of Early - stage Lung Cancer (Stage I - IIIA)

1. Phase IB: For newly diagnosed postoperative ALK-positive patients, Ensartinib is employed for adjuvant therapy.

2. Phase II - III (Operable)

(1) For EGFR-positive non-squamous cell carcinoma patients with EGFR-sensitive mutations: After surgery, it is advisable to administer Almonertinib for adjuvant targeted therapy subsequent to adjuvant chemotherapy.

(2)For postoperative ALK-positive patients: Ensartinib is recommended for adjuvant therapy.

(3) Platinum-containing chemotherapy combined with Nivolumab: The neoadjuvant therapy (preoperative) and adjuvant therapy (postoperative) modalities of platinum - containing chemotherapy combined with Nivolumab are classified as Level I recommendations.

II．Treatment progress of advanced EGFR mutation - positive lung cancer

1. First - line treatment: New options such as Limertinib and Almonertinib combined with chemotherapy have been added, and they are listed as Level I recommendations.

2. Rare mutations: For rare mutations such as G719X, S768I, and L861Q, Afatinib has been added as a Level I recommended therapeutic drug.

3. Back - line treatment (after drug resistance):

(1) For the situation of resistance to EGFR-TKI and chemotherapy, Sacituzumab Tirumotecan is listed as a Level I recommended therapeutic drug for EGFR - TKI and chemotherapy resistance.

(2) In view of drug resistance problems caused by MET amplification, the treatment plan of Savolitinib combined with Osimertinib is recommended. 

III．Update of Treatment Strategies for Advanced Non-Small Cell Lung Cancer without Driver Genes

In the treatment of non-squamous and squamous non-small cell lung cancer, for patients with a programmed death ligand-1 (PD-L1) expression level of ≥1%, the clinical guidelines have explicitly elevated the recommended level of Ivonescimab to the highest level, namely, Level I recommendation. Simultaneously, the treatment options have been further diversified. The immune checkpoint inhibitor combination regimen of Nivolumab and Ipilimumab has been added and listed as a Level II recommended strategy and incorporated into the updated guidelines.

Overall, the contemporary clinical diagnosis and treatment of non-small cell lung cancer have been structured into a comprehensive precision medicine system featuring an interlocking relationship of “precision detection - molecular typing - personalized treatment”. Standardized and comprehensive molecular pathological testing at the initial diagnosis stage of the disease serves as a crucial prerequisite for initiating all efficient targeted therapies and immunotherapy regimens. The authoritative clinical practice guidelines, which are based on the latest international evidence-based medical evidence and are continuously and dynamically updated, fundamentally guarantee that every lung cancer patient can receive the most effective and highly individualized treatment plan supported by current scientific evidence.

Reference:

Chinese Society of Clinical Oncology (CSCO) Guidelines for the Diagnosis and Treatment of Non-Small Cell Lung Cancer 2026