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Chemotherapy Selection for 1st line Non-Small-Cell Lung Cancer (NSCLC) — The Importance of Getting it Right the First Time
Introduction: Why Chemotherapy?
Every cancer therapy has two purposes: to improve duration of life, and to improve quality of life. Every other measure of chemotherapy success, such as response rate or progression-free-survival, is a surrogate to these two true goals. I am using the broken record as my pseudo-apology for repeating this mantra repeatedly on GRACE, to my colleagues, and in my mind every time I make a treatment decision.
Chemotherapy is the most important treatment for achieving these two goals in stage IV disease. Stage IV means that the cancer has spread and is no longer curable. Incurable is not the same as untreatable. Cure means eliminating every last cancer cell. Treatment means providing real benefit, in the form of achieving these two goals.
Cancer cells are microscopic. The tip of a pen is the size of more than ten billion cells. So, if a single cell has spread to a site, say, the liver, you won’t be able to see that cell on a CT or even the most sophisticated PET/CT. So, once you see the cancer having spread to distant sites, it becomes systemic-in more sites than you can see; we call this “metastatic” or stage IV disease. To achieve our two key goals, you need to knock down the cancer everywhere-the places that you can see and those you can’t. Chemo gets almost everywhere in the body and is therefore the best and most important way to do this for most patients with metastatic disease.
An Introduction to Lung Cancer
The GRACE Lung Cancer Reference Library is made possible by an educational grant from Pfizer, who had no input in its contents.
What is cancer?
One of my patients once told me that she likened her cancer cells to misbehaving children and I think that this was a wise explanation. When a baby is born, it starts as a sperm fertilizing an egg, creating a single cell. That cell is pluripotent, meaning that it is capable of making all of the different kinds of cells that will ultimately be needed in the body. The cell will divide, then divide again, then divide again. In the process, the “daughter” cells become increasingly specialized. By birth, a baby has many different kinds of cells, each with very specialized functions and most of them have lost the ability to divide further or spread to other parts of the body. They are programmed to die in response to signals from other cells.
Each of these cells is a little factory, performing its specified functions. The tools that the cell uses to carry out these functions are called proteins. In order to make a protein, the cell starts with the DNA blueprint that is housed in a structure called the nucleus. The nucleus can be thought of us a little fortress-enclosed island containing stacks of blueprints in a big lake that is the cell. The DNA is transcribed (copied) into stuff called RNA, which travels out of the nucleus into the cytoplasm (which could be thought of like the water in the lake). In the lake, the RNA attaches to a structure called the ribosome (think of it as a small, floating protein factory) where it is translated into a protein.
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