One of the issues that we've commonly discussed and debated here is the question of when a local approach like surgery and/or radaition may be appropriate for I recently saw a patient of mine who I first met more than four years ago. At that time, he was only 37 years old and had just been diagnosed with stage IIIA NSCLC with several N2 nodes involved, after having quit smoking a couple of years earlier. He had actually initiated treatment with another local oncologist, a plan of chest radiation along with concurrent weekly carbo and taxol. He had also met with one of the expert thoracic surgeons I work very closely with, Dr. Eric Vallieres, who felt that he would be a good candidate for surgery after chemo and radiation. In truth, the extent of his disease in his mediastinum (midchest) was enough that I felt that an alternative approach of aggressive chemotherapy and radiation without surgery was a reasonable alternative. But Rob was one of the most informed and proactive patients I've encounted in my own practice and came to learn as much about the controversy around how to manage stage IIIA NSCLC as his physicians. Not only did he shape the plan that led him to surgery after "induction" chemo and radiation, he pushed for post-operative prophylactic cranial irradiation (PCI), though that isn't a standard approach at this time (and I had expressed some misgivings despite the compelling rationale). He had also received a few doses of post-operative chemo with gemcitabine and navelbine, which was as much as even an aggressive-minded man in his late 30s could take after chemo, radiation, and surgery.

Of note, he had received this care through another oncologist, but he transferred his care to me about a year after he had completed these treatment. However, before he came to me, he had undergone a repeat PET/CT that showed an upper abdominal lymph node that lit up on PET, with no other abnormalities. In fact, he had just undergone an exploratory where they found and removed that node, which was recurrent cancer. He came to me for consideration of post-operative therapy, and the entire team had an extensive discussion of the possibilities (this team definitely including the patient, along with surgeon, radiation oncologist, and myself). Though we were without any real precedent and a potential of making him feel worse for no clear benefit, he was young, aggressive, knowledgeable of the balance of potential risks and benefits, and we thought it might still be possible to cure him. He had gone a year and had a single lymph node recurrence, with no evidence of any disease elsewhere. In fact, due to some manipulations that the surgeons had done at the time of his surgery, that lymph node was felt to potentially have drained directly from the surgical bed, so there was a chance that this area of disease hadn't spread through the bloodstream.

Though I was a little skeptical, he was knowledgeable 39 year old who understood the risks and might possibly be cured, so we went all out. He received radiation to the area of his upper abdomen near the resected lesion, along with concurrent weekly cisplatin and navelbine, which he tolerated well, fortunately. And after that I gave him three cycles of taxotere, an agent he hadn't received before, based on the favorable results of "consolidation taxotere" after chemo/radiation for unresectable advanced NSCLC (see prior post), although that work wasn't supported by further research reported since then (see prior post). He completed taxotere in May of 2006.

Unfortunately, in January of 2007, a repeat scan (we alternated CT and PET/CT scans) showed a new PET-avid lymph node right at the base of his left neck. After a needle biopsy confirmed cancer, he saw a head and neck surgeon who performed a full surgery that showed just a single node with recurrent cancer among the multiple nodes removed and checked. Again, there was no evidence of disease anywhere else in his body.

We discussed what we might do after his surgery and decided to have him receive radiation to the area, but I recommended against further systemic therapy. Why? I felt that by this time he had received so many different treatments over such a long time that I was skeptical that further treatment would make the difference if everything else he had received didn't. I recommended reserving our remaining active treatment options for some time on the future if/when he developed a multifocal recurrence. In the meantime, if he developed a new single area of disease every few years, perhaps a local therapy of surgery and/or radiation to the involved area would be the best approach.

Two years later, he's now 42, and his scans haven't shown any recurrence of disease since then. He feels well, has no limitations in his lifestyle, works full time, travels extensively, and takes nothing for granted. Both of us understand that we may not have seen the last of his cancer, but the intervals between his recurrences have increased over time. Perhaps he'll be the remarkable exception of oligometastatic disease that is truly cured. Short of that, he's now approaching the five year mark after his diagnosis and expecting that even if he continues to develop recurrences, we'll take them in stride and plan to manage this as a very chronic disease.

To emphasize the features that would make me consider a local treatment for a patient with metastatic/recurrent cancer with a thought of possible cure, they are:

1) a single area of metastatic disease
2) a long interval of time without evidence of multifocal recurrence = time for a truly multifocal cancer to "declare itself" (if not, you can be more confident that you won't see multiple new lesions before the patient has recovered from local treatment)
3) a very informed, motivated patient who understands that this isn't "standard treatment"
4) the probably that the local therapy will be well tolerated and not too dangerous -- this is a combination of the features of the treatment (local radiation usually less problematic than a major surgery) and the fitness of the patient (riskier in a more frail patient than in a very fit younger one)

Finally, it's important to highlight that this is all highly individualized, non-standard, and highlights how variable the biology of cancer and treatment approaches can be. It's also a team approach, and some of the management decisions weren't exactly the way I might have pursued them if I were the only decision maker, but the other physicians and the patient play very important roles, as they should.

Rob remains grateful for the opportunity for an uncoventional approach. We can congratulate a likely 5-year survivor who I hope to have the opportunity to care for over many more years.