Hello there,
My father has recently been diagnosed with NSCLC adenocarcinoma and because of a malignant pleural effusion (MPE) the cancer has been deemed advanced stage, though there is no evidence of cancer elsewhere in his body. The primary site in his right lung is <1cm and there are a few tiny spots on the lining but no lymph node involvement. Is advanced stage lung cancer always inoperable? I have read that there is controversy surrounding MPE IV staging, and some medical papers suggest MPE patients with N0-1 disease may be candidates for resection. I am concerned that the guidelines for stage IV nsclc treatment mean that my father is not being considered for surgery when it may offer him a cure. Apparently there are some reports of lung cancer patients with only a malignant pleural effusion and no other metastatic sites that have had long-term cures with chemotherapy and surgery. My father is currently on his third dose of cisplatin/pemetrexed and no other treatment options have been discussed at this point. Should we ask for a referal to a thoracic surgeon? Do you have any other suggestions for treatment routes we should look into, like EGFR testing etc? My father's oncologist seems very capable but his NHS ward is overstretched and underfunded. Many thanks in advance for any help and advice you can give.
NSCLC with Malignant Pleural Effusion staging and surgery - 1272508
fawkes
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Reply # - January 9, 2016, 06:39 AM
Hi fawkes,
Hi fawkes,
Welcome to GRACE. I am sorry to hear of your father's diagnosis. The problem with surgery for lung cancer with a pleural effusion is that the cancer cells spread to the pleura via the bloodstream, and once cancer cells are in the bloodstream they can eventually appear anywhere else in the body. Because of this, the standard treatment is systemic therapy designed to kill cancer cells wherever they may be. Surgery places a great burden on the body, making it impossible for a patient to receive systemic therapy until sufficiently healed from surgery, which can cause difficulty if the cancer spreads during that healing time.
Dr. West has written about this subject:
" We’ve had similar discussions in our tumor boards, but other series have shown less favorable results. Our surgeons, who had been receptive to the concept and are usually quite eager to surgery any time it’s appropriate (and sometimes even when it isn’t), have reviewed the range of these kinds of reports and don’t do this surgery.
It’s worth bearing in mind that these small series are also subject to a lot of selection bias, as well as publication bias. Selection bias means that patients who pursue an unusually aggressive treatment approach that is beyond the typical standard of care aren’t the same as the general population: they may be unusually young, fit, aggressive-minded, have unusually little disease, or other factors that not only make them candidates for a different approach but also make them likely to do better than the general population no matter what they do.
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Reply # - January 9, 2016, 06:41 AM
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"Publication bias refers to the tendency for positive results to be reported and published, while negative results are ignored, never written up as potential publications, and if submitted for consideration may not be accepted. So a single positive report may not be an accurate picture of reality if there are in fact 5 or 10 other series that actually showed little or no benefit, but they remain unwritten or unpublished.
There is always room for good clinical judgment and often an individualized approach for a particular case, but the clear, prevailing standard around the world for someone with a malignant pleural effusion and/or pleural nodules is systemic therapy with no role for surgery." - http://cancergrace.org/topic/is-surgery-an-option-in-stage-iv-nsclc#pos…
You may want to consider a second opinion, but as you can see most oncologists will favor systemic therapy.
JimC
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