Chemo after succesful BACs removal - 1254664

Hello iharrold,

I'm very sorry your dad is in this position. Your right in saying chemo is a difficult treatment to withstand and that is why it is only given post operatively to some cases and not others. There isn't any other treatments that have shown to help. Chemo has been shown to do more harm than good in the most stage Ia cases of lung cancer but it can add around a 5% chance to the possibility of cure in stage Ib-III if the patient is up to it. It is called adjuvant treatment and is extensively written about here on Grace. Below is a link on the subject with further reading at the bottom of the discussion. You may need to log out to use our search engine depending on your browser. Also our focused cancer info has drop down menu on the right column that will be helpful.

Let us know if you have follow up questions.
Here's hoping your dad is cured,
Janine

These should give you a good start,
http://cancergrace.org/lung/2013/02/11/cip-adjuvant-chemo-for-smaller-h…
http://cancergrace.org/lung/2010/05/17/systemic-therapy-for-resected-ns…
http://cancergrace.org/lung/2010/06/18/adjuvant-chemo-stage-ib-nsclc-ca…

Dr. West is a world expert on BAC and may have more to say. In my practice, the choice to administer chemo usually depends on stage. If BAC become invasive adenocarcinoma, and that invasive cancer has a positive node or mass >4cm, then I consider chemo. However, BAC can often be harder to stage. Sometimes, several small non invasive BAC masses are resected. In these cases, my personal bias is usually against chemo, although I certainly wouldn't judge a doc who considered it. There are a few major situations that could be the case after such a surgery, and no way with year 2013 technology to know which is the case:

1) No cancer cells left- surgeon has cut them all out
2) Microscopic cancer cells are left, but not sensitive to chemo
3) Microscopic cancer cells are left and will not be killed by chemo, but their growth will be halted for a time
4) Microscopic cancer cells are left and will be killed by chemo

In my opinion, there's only clear benefit to chemo in situation #4. In situations #1 and #2, chemo can cause side effects, but cannot improve cancer outcomes. In situation #3, chemo may help, even if it doesn't offer cure. However, this same benefit could likely be accrued later, once the cancer grows. And, when there's visible cancer, you can follow it to know if you're giving the right chemo or not (you can watch macroscopic cancer grow or shrink, but there's nothing to see with microscopic cancer).

I really agree with the assessment by Dr. Weiss. I would say that the rules for BAC are or should be th same as those for another adenocarcinoma, except that if the cancer is largely or completely non-invasive, the decision to favor adjuvant chemotherapy is really a function of the diameter of the invasive portion of cancer. In other words, if it's a 4.2 cm lesion and 90% of it is non-invasive, it would be very appropriate to favor no chemotherapy, even if we would often favor adjuvant chemotherapy for a 4.2 cm invasive lung adenocarcinoma or other invasive NSCLC.

If the question of whether to give adjuvant chemotherapy is because there are multiple nodules that have been resected, that's a data-free zone. We just don't have any information to guide us, and I have a very individualized discussion with patients. I think you could make a very strong argument to consider chemo or to hold it and watch things. If it were two sub-cm nodules, I think I'd be extremely reluctant to pursue chemotherapy. I might be more inclined if there were 3 nodules, combined invasive and non-invasive, that were more than a centimeter each. But there's no right or wrong answer.

I would have little to no enthusiasm for any treatment aside from chemotherapy. As weak as the evidence is for giving chemo to reduce the risk of recurrence in BAC, there's just not a scintilla of evidence to support giving targeted therapy or vaccine therapy or alternative therapies to prevent recurrence of BAC after surgery that leaves nothing behind.

Good luck.

-Dr. West

PS: There are many agents and combinations of chemotherapy, with an enormous range of side effects and tolerability, so I would really hesitate to draw broad conclusions about what chemotherapy is like. It's kind of like one kind of food and drawing conclusions about what food is like.