Stage 1b non small cell lung cancer - 1289993

Hi jb67,

Welcome to Grace. I'm sorry you're in this predicament but glad that you're doing so well. Dr. West addressed this very issue in a previous thread. He begins his statement by addressing the fact that BAC histiology doesn't play a role, so his statement really addresses your situation as well.

He said, "Making a recommendation for or against chemo just based on the vagaries of the staging system isn’t how I or most other lung cancer experts approach the question of the potential value of post-operative chemotherapy. In the absence of lymph node involvement. the leading recommendation of a threshold for favoring chemo is 4 cm. I might use the presence of visceral pleural involvement (VPI) to nudge toward a recommendation in a highly motivated patient with a 3.5 cm tumor, but I would consider a 2 cm tumor with no lymph node involvement to be pretty far from an appropriate threshold for recommending chemotherapy, regardless of other features such as VPI." http://cancergrace.org/topic/bac-stage-1b-lung-cancer/#post-1261283

There is a certain amount of risk involved in adding chemo treatment to an already weakened post op system. However by adding chemo (adjuvant therapy) you add a few percentage points (single digits) to the cure rate (sometimes the chemo wipes out that last bit of cancer that will become metastatic). Studies suggest the risk of harm is higher than the benefit for sub 4 cm or so even with pleural involvement. Dr. West clearly states he isn't very motivated to proceed with chemo for someone with a sub 4 cm 0 node involvement.

I hope you do well.
Janine

Catdander,
Thank you for this post. It has put my situation in perspective and cleared up some questions I had.

I have Ib pT2aN0 papillary 80% and acinar 20% adenocarcinoma with one margin to close to call negative because it involved the chest wall through a pleural extension. I had a right middle lobe lobectomy 6 months ago. No adjuvant tx. The hardest part of this is waiting and not knowing but most of all not being able to do anything about it. I also had a wedge resection of the same lobe 1 year ago that was basically benign of unknown etiology. My story is too long and convoluted to go into.

Thanks for listening

Hi jb67,

In addition to the great information you've already received, I would just add this link to to Dr. Sanborn's review of some of the studies of adjuvant chemotherapy in early-stage lung cancer. She notes the factors of size of the tumor, health of the patient and lymph node involvement, to which you could add a complication such as pleural involvement as a possible consideration in making an adjuvant treatment decision. That's probably why you didn't find consensus among the three oncologists you consulted.

JimC
Forum moderator

If I were in your position I would also be wondering about getting adjuvant treatment either as standard of care or part of a clinical trial. Firstly from what you wrote, it is not clear if you had positive margins and this would up the risk from a standard T2 tumour stage case. Secondly I don't know what " it involved the chest wall through a pleural extension". That might make it T3 according to the 8th ed IASLC guidelines

T2: tumour >3 cm but ≤5 cm or tumour with any of the following features:
involves main bronchus regardless of distance from the carina but without involvement of the carina
invades visceral pleura
associated with atelectasis or obstructive pneumonitis that extends to the hilar region
involving part or all of the lung
T2a: tumour >3 cm but ≤4 cm in greatest dimension
T2b: tumour >4 cm but ≤5 cm in greatest dimension
T3: tumour >5 cm but ≤7 cm in greatest dimension or associated with separate tumour nodule(s) in the same lobe as the primary tumour or directly invades any of the following structures:
chest wall (including the parietal pleura and superior sulcus)
phrenic nerve
parietal pericardium

https://radiopaedia.org/articles/non-small-cell-lung-cancer-iaslc-8th-e…

If it is T3 then you are at least stage IIB and would statistically benefit from adjuvant chemotherapy. In your situation, I would discuss my concerns with my oncology team and go from there. Personally, I was misclassified as IIB and got adjuvant chemo and then turned out to be only 1B when the 8th edition guidelines came out.

FYI, timing is important with adjuvant treatment. After about 8 weeks post op or post radiation the chances of adjuvant treatment raising your possibility of cure is pretty slim. Most oncologists want to start adjuvant chemo by 6 weeks out from local treatment (surgery and/or radiation). At it's best adjuvant raises chance of cure less than 10 percent. The more time that passes after local treatment the less chance adjuvant chemo will kill remaining cancer cells.

metafran, I get the "too long and convoluted". I think everyone's story is that way in it's on way. When you hear oncologists say "cancer can and will do anything" or "every individuals' cancer is it's own type of cancer" I think that's what they mean. Everyone's cancer is odd or unusual in some ways. My husband had a pancoast tumor that we couldn't tell whether radiation killed it because of scarring and inflammation until it didn't grow without treatment. A 3cm mass in the other lung that couldn't be diagnosed was assumed to be cancer because it looked like cancer and it showed up big and quick like cancer and he already had cancer, but it evidently wasn't because Don doesn't have cancer growth 5 years post treatment.
But watching and waiting has gotten soo much easier yet scanxiety can still wreck havoc. I'll stop here so not to be long and convoluted but it can easily go there. :0

All the best of hopes and luck y'all,
Janine

What Janine writes about adjuvant therapy is generally true. How tight the interval between curative intent treatment and adjuvant therapy needs to be depends on the type of cancer though. For lung cancer delays up to 18 weeks still are effective (unlike breast cancer).

Since your lobectomy, Metafran, was 6 months ago that is outside of the range that has been studied. I think the best you can do now is to get close monitoring. Also chemotherapy definitely has risks, not only of mortality but also of permanent damage like neuropathies and hearing loss. How often are your ct scans?

In the National Cancer Database, adjuvant chemotherapy remained efficacious when started 7 to 18 weeks after non-small-cell lung cancer resection. Patients who recover slowly from non-small-cell lung cancer surgery may still benefit from delayed adjuvant chemotherapy started up to 4 months after surgery.

From "Association of Delayed Adjuvant Chemotherapy With Survival After Lung Cancer Surgery."

https://www.ncbi.nlm.nih.gov/pubmed/28056112

Thanks onthemark! While reading the following post from JAMA I thought how much it sounded like Dr. West. It was. I found this related post to the one onthemark linked to about adjuvant therapy between 18 days and 4 months post surgery. It's a small world :) https://jamanetwork.com/journals/jamaoncology/fullarticle/2595780

That's a great article by Dr. West. Thanks for sharing it, Janine! And yes I linked the same study that Dr. West referenced in his article.

Right, I read your link and wanted to see what others were saying about it so I googled the title of the study and came up with jamanetwork's article which led to "editor's note" was Dr. West's article.

one of my favourite places on the web is to read papers that I can find at
scholar.google.com

It's wonderful to find other people who like to read and write papers.