One of the very common themes that emerges in the questions from the GRACE community is whether a "local therapy" such as focal radiation or surgery could be useful for advanced NSCLC.  There's an FAQ question and answer about the general concept of why treatment directed to a specific area (i.e., a "local therapy", as opposed to a systemic therapy that works throughout the body) isn't typically recommended for metastatic cancer, but local therapies are still often discussed and may have a role for patients who have more advanced NSCLC.   Very often, I'm coming down against the concept of local therapy when people here ask, but there are some settings in which local therapies are very appropriate, in addition to others where we might strongly consider it. I work very closely with my radiation oncologists, my thoracic surgeons, and my interventional pulmonologist -- who all provide local therapies -- and we are all part of a team that share patients depending on their case needs. But I do feel that local therapies are all too often misapplied, whether because of financial motivations of the practitioners or the misguided, unclear rationale for doing it ("magical thinking"), which I see as creating a fundamental disconnect between a patient's expectation and the reality of what such an intervention can deliver.

The clearest role for local treatments in metastatic lung cancer is to improve QOL and reduce symptoms. Indeed, that's exactly the place where they have a clear role. Radiation, for instance, is appropriate in metastatic disease in four basic circumstances:

1) brain metastases, which cause symptoms from local growth and swelling, or usually will very soon after detection, if not treated effectively

2) hemoptysis (coughing up blood), where radiation can treat local bleeding from erosion of the cancer into adjacent blood vessels quite effectively

3) local pain, such as from a bone or soft tissue lesion, in which case radiation-induced shrinkage can reduce that and improve pain effectively

4) airway compression, in which case radiation-induced response can lead to better air movement

Radiation isn't the only form of local therapy. Mechanical ones like surgery (removing a single brain metastasis, treating a collapsed vertebra with kyphoplasty) or interventional pulmonology techniques (removing tumor from within an airway or placing a stent in an airway compressed from outside of it), may also be helpful in many cases.  Other common local therapies are a pleurodesis or placement of a PleuRx catheter to control shortness of breath and the cough that can accompany a recurrent large pleural effusion.  These interventions are all extremely appropriate and offer quality of life benefits/symptomatic benefits first and foremost, though they may also improve survival.

The problem that I see is that local therapies are often recommended far beyond these settings, such as for asymptomatic and multifocal metastatic disease, where multiply-directed stereotactic radiation is pursued as a presumably curative technique.   While this might sometimes work for people with a single focus of metastatic spread (see my post about when, in my opinion, breaking the general rules and treating oligometastatic lung cancer with curative intent makes sense), focusing on local therapy with curative intent when the cancer isn't "oligometastic" veers into the realm of magical thinking. Too often, patients and physicians pursue local therapy because they really just want to "treat the scan" to make themselves feel like they're just doing something, shrinking or removing the cancer by brute force, but if the cancer is active in multiple sites, it can spread and cause new problems before the patient recovers from side effects of local therapy.  And even if the treatment has very little risk, doing a pricey treatment that has no realistic probability of benefit just because it's possible doesn't make a lot of sense.

I recognize that it's not only hopeful patients are pressing for these treatments when they don't necessarily make good sense. Many physicians make these kinds of futile recommendations and referrals every day, as I see this in the practice patterns all around me. But I believe the true motivation  for these doctors is that it is easier for them to sidestep the emotional and time-consuming challenge of discussing the realistic limitations of our standard therapies, especially after a few lines of treatment, than to just glad hand and send a patient out of your office for an intervention that truly just going through the motions. There are also some doctors who are misinformed enough about the biology of metastatic cancer, or just subject to so much wishful thinking on behalf of their patients, that it's easy to slip into a collective delusion of what a local therapy can provide.

Highlighting that certain treatments are a poor option for many patients is far less fun that describing a wonderful new therapy for patients.  But local therapies still have a clear role for many patients with advanced lung cancer.  Not only can they be a critical component in maximizing quality of life and minimizing side effects, they may also offer a realistic possibility of an extraordinarily good outcome for well selected patients.  They just aren't broadly helpful when used indiscriminately as a solution for most people with advanced cancer.