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Limited Resections for Very Small NSCLC Tumors and BAC
While lobectomy or pneumonectomy may be the surgical treatment of choice for most NSCLC tumors in younger, fit patients, a limited resection may be an ideal choice in certain settings. In my previous post I discussed the data supporting a limited resection in older patients, who are likely to have competing health risks that may make it less critical to pursue the most aggressive surgical strategy. Another situation in which a sub-lobar resection may be particularly appealing is when the tumor is quite small and/or has characteristics suggestive of an indolent natural history. In such cases, a lobectomy may be more surgery than is required. There are trials now asking the question of whether patients with the most favorable features based on size or histology (microscopic characteristics) may do as well or better with limited resections than the standard lobectomy or pneumonectomy. Continue reading
Targeted Therapy for Selected Populations in NSCLC
In my last post, I described the somewhat disappointing results for tarceva compared with chemotherapy in a trial of unselected advanced NSCLC patients with a marginal performance status. However, EGFR tyrosine kinase inhibitors like iressa and tarceva were developed as targeted therapies, so perhaps they might prove to be more effective if used selectively, in a targeted population. That targeting might be based on clinical characteristics like using it in never-smokers or bronchioloalveolar carcinoma (BAC), or it might be based on molecular markers like mutations in the EGFR gene or overexpression of the number of copies of the EGFR gene, as determined by fluorescence in situ hybridization, also known as EGFR FISH testing. All of these methods have been employed in early but very promising studies of iressa or tarceva in selected populations. Continue reading
The Risk of Overtreating Indolent Bronchioloalveolar Carcinoma
Bronchioloalveolar carcinoma, or BAC, is a subtype of lung adenocarcinoma that has a tendency to progress more slowly, stage for stage, than other types of lung cancer. There are many patients who experience symptomatic and significant progression over months, and rarely patients have a very aggressive and fulminant form of the disease. However, many patients with BAC experience slow growth that raises the risk of potentially overtreating it, with the possibility of detrimental effects from that.
As someone with a particular interest and expertise in BAC, I see the situation with BAC as being similar to the issues we face with prostate cancer. Once a blood test for detecting prostate cancer emerged (prostatic serum antigen, or PSA), it became possible to identify 200,000 men in the US per year who had prostate cancer. The problem is while a huge proportion of men will develop prostate cancer as they get older, many will have an indolent cancer that will not really threaten their survival, and for which treatment with surgery or radiation can have significant long-term side effects. A low grade prostate cancer is well known for being a cancer men can “die with, but not of”. In other words, men can have a prostate cancer that would never directly threaten them, and they can go on to a ripe old age before succumbing to heart disease or another non-cancerous condition. Continue reading
Is Rash a Good Thing with EGFR Inhibitors?
An acne-like rash or dry skin is a very common side effect of the drugs that target the epidermal growth factor receptor, with approximately 3/4 of patients who receive the EGFR tyrosine kinase inhbitor tarceva/erlotinib experiencing skin toxicity. Similar skin toxicities are also seen, but a bit less commonly, with the very similar drug iressa/gefitinib, and also frequently with erbitux/cetuximab, a monoclonal antibody that is less well studied in lung cancer. But since the earliest clinical trials of these agents, there have been questions of whether the rash is something more than just a potentially problematic side effect, but rather a marker of someone likely to do well with these agents.
Do Never Smokers with Lung Cancer Have a Different Disease?
Just a few years ago, the only distinction in the field of lung cancer that meant anything was small cell vs. non-small cell. The different types of non-small cell, like adenocarcinoma vs. squamous cell vs. large cell, were of little interest and didn’t change management (only a very recent development). And although we often asked about smoking history, the answer never changed our treatment plan. Only in the last few years have we come to recognize that we will do better as “splitters” than as “lumpers”, by tailoring our treatment recommendations to the clinical and molecular feature of one particular patient and tumor at a time, rather than using a one size fits all approach.
First, some definitions. Although there is a little variation, most of the lung cancer research community has come around to a definition of a “never-smoker” as less than 100 cigarettes in a lifetime. A “former smoker” is more than that and has quit smoking for at least a year. A “current smoker” is anyone else, so less than a year after quitting, a patient is still considered a current smoker. Continue reading
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