is chemo before surgery preferred for stage IIIA - 1255325

Hi Chris, It would be easy if we could clear this up for you.
The standard of care for surgically respectable stage III nsclc has been surgery with adjuvant chemo and maybe radiation. This all depends though on the site of the tumor. My husband for example had a tumor that grew at the apex of his lung and into his chest wall and ribs (a pancoast tumor.) The standard of care for his would have been chemo radiation before (neoadjuvant) and after if he were up to it. It turned out an mri spotted a spine met and the staging was upped to IV and no surgery option. But it does depend on the location. If a tumor needs to be shrunken so it can be surgically removed then chemo and maybe radiation is feasible.
There is a lot written on the subject so don't miss the further reading options at the end of this post. http://cancergrace.org/lung/2011/12/03/chest-trial-scagliotti-neoadjuva…

Hi Chris, This is going to be very short. My 3rd time to write this post. I've just changed from safari to chrome. Safari was very helpful in that it would keep my writings in tact when I move forward or back, which has happened, each way. Chrome doesn't save it for me. Drats is the most appropriate thing I can say as a moderator.

A quote from the discussion of the CHest trial linked to in my previous post, " The “hazard ratio” of relative improvement in OS for stage IIB/IIIA patients was 0.42, meaning that the chance of a patient in this group who received chemotherapy would be alive was more than twice as great at a given time point than a patient who underwent surgery alone."

This is what the data suggests but also the trial was underpowered. (I believe that means there wasn't enough people to give an accurate showing of what can really be expected)

I'd suggest linking the post I linked to above not just for the poster but for all those who read the thread. That explains a lot of the thinking behind why the 50% statement isn't really right on.

I imagine Dr. West will explain it better later on this evening.

All Best,
Janine

I just want to add that it would also depend on the size not just location.
Take care, Judy

This is a very big topic, but the short answer is that adding chemotherapy or chemotherapy and radiation to surgery for stage IIIA NSCLC markedly increases the chance of a good long-term outcome. The magnitude of benefit varies from trial to trial, but an approximate doubling of 3-5 year survival is about right.

Conventionally, if stage IIIA NSCLC is documented before surgery (in someone with a resectable cancer, as not all stage IIIA lung cancers are best served by surgery even after other treatments), the most common approach that is recommended is chemotherapy or chemo and radiation followed by surgery. In fact, there is good reason to believe that patients could do comparably well receiving initial surgery followed by chemo or chemo/radiation, but practically speaking, it's more likely a patient will get through pre-operative treatment followed by surgery than surgery followed by post-operative treatment.

Overall, there are many ways to treat locally advanced NSCLC that can still be sensible, and it's reasonable to individualize the approach based on the features of the patient's cancer and the strengths of the treating center. However, the general idea is that surgery alone is not optimal, and the most favored approach is pre-operative "induction therapy" (also known as "neoadjuvant therapy") followed by surgery in patients with a resectable stage IIIA NSCLC.

-Dr. West

IIIA is the "wild west" of lung cancer. Almost every approach combining chemo, XRT and surgery has data behind it: chemo then surgery, chemorads then surgery (as long as the surgery would be just one lobe, not half a lung), surgery then chemo, surgery then chemo and rads. The only "mistake" one could make would be leaving out chemo--all of the positive trials included chemo.

In practice, we try to individualize choice of therapy based on the exact situation of the patient. In my opinion, this is most effectively done by a tumor board of experts in lung cancer. Many large centers in the Phili area offer such tumor boards. I trained at UPenn and am most familiar with the tumor board there, which was amazing. I am also familiar with the medoncs at Fox Chase and Jefferson and can vouch that they are kind, caring, and talented and probably also have great tumor boards.

The CHEST trial comments were really primarily about patients who don't have stage IIIA NSCLC identified pre-surgery. There has long been a distinction between patients who don't have mediastinal node involvement, for whom up front surgery is the standard of care, followed by chemo for appropriate patients, and those with mediastinal node involvement identified prospectively, for whom pre-operative therapy is the more common approach. The magnitude of benefit of other treatments beyond surgery is comparable whether the order is neoadjuvant (pre-operative) therapy followed by surgery or surgery followed by adjuvant (post-operative) therapy, but the convention is that the need for non-surgical therapy is too great in stage III to defer it, since it can be challenging to get people through post-operative chemo or chemo/radiation after a big lung surgery.

So to get back to your question, the CHEST trial looked at a wide range of surgery patients, including stage I, and my comments were really directed at a group defined differently than stage IIIA/mediastinal node-positive as a stand-alone group. In fact, that trial wouldn't have been acceptable in the US, because we don't put stage IIIA patients with mediastinal nodes in the same treatment category as patients with stage I or II NSCLC, as they did in the CHEST trial. I'm not saying it's wrong to do so, but... yes, I am. It's really not what I would consider acceptable.

-Dr. West