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Dr. Jack West is a medical oncologist and thoracic oncology specialist, and Executive Director of Employer Services at the City of Hope Comprehensive Cancer Center in Duarte, CA.

Beyond Stage & Tumor Size: More Pathology Variables Associated with Risk of Recurrence after Surgery
Tue, 10/02/2007 - 12:56
Author
Howard (Jack) West, MD, Associate Clinical Professor, Medical Oncology, Executive Director, Employer Services, Founder, President and CEO of GRACE

The decision about pursuing post-operative treatment is often difficult and requires carefully weighing the risks of treatment with potentially challenging and even dangerous chemotherapy against the potential to eradicate micrometastases and actually lead some people to be cured who otherwise wouldn't be. It's important to remember that some people are already cured, while others won't be cured even with treatment. We're pursuing treatment for the 5-15% higher survival rate at 5 years from adding chemo, presumably representing the proportion of people who have micrometastatic cancer cells that are apparently eradicated by getting 3-4 cycles of platinum-based chemotherapy:

Scagliotti adjuvant chemo explanation

(Click image to enlarge)

The general guidelines we use to assess risk for recurrence include stage of the cancer as the primary focus. I also described the relevance of tumor size as an important factor to stratify risk of recurrence in my recent post on that topic. But there are other potentially relevant factors for people who have cancers that are "on the bubble" about whether they have enough risk to justify the side effects and some real risks of post-operative chemotherapy.

I've covered the topic of tumor grade being predictive of recurrence risk in a prior post. In addition to stage, primary tumor size, and cancer grade, there is the factor of tumor histology subtype (squamous vs. adenocarcinoma). Presumably because of its greater tendency to be associated with micrometastases and spread early, patients with stage I adenocarcinomas (stages IA and IB) have been shown to have a higher risk of recurrence than those with squamous cancers (abstract here):

Early stage NSCLC survival by histology

Remember also that patients with stage I adenocarcinomas also have a higher risk of being "upstaged" by finding unexpected cancer involvement in the mediastinal (mid-chest) lymph nodes, as I described in a prior post. This is the same theme, that squamous cell carcinomas tend to remain localized longer than adenocarcinomas. On the other hand, BAC tumors have a different behavior than invasive adenocarcinomas and tend to be associated with a more favorable survival (described in prior post)(abstract here):

Breathnach stage I BAC survival

Finally, there is also the minority of patients large cell neuroendocrine carcinomas, who appear to have a less favorable prognosis than other NSCLC subtypes (described in a prior post).

Finally, another factor to consider is the involvement of the visceral pleura, the lining on the outside of the lung. This is reflected in the staging system, since even a smaller tumor that measures less than 3 cm becomes a stage IB NSCLC if it involves the visceral pleura. Here's a survival curve from a series of stage I cancers that shows the difference in survival between those patients who had or did not have visceral pleural invasion (sometimes abbreviated VPI)(abstract here):

VPI Stage I survival

So that's a lot of factors from the pathologic report, all worth considering when weighing the pros and cons of chemotherapy after surgery in more boderline cases. And we haven't gotten to imaging factors yet. That's the next topic...

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Hi Stan! It's good to see you. I can only imagine what this last year has been like for you and hope the grieving is getting more manageable every day. GRACE...

It is so good to hear from you, and my sentiments are the same as Janine's.  You are definitely why we do this, and we truly appreciate your kind words.  Happiest...

Stan, thanks so much for sending this very kind note. It is because of people like you and Sara that we are so tirelessly dedicated to our mission of helping to...

Hi and welcome to GRACE.  I'm sorry mother is experiencing oligoprogrssion.  This often happens when some of the cancer cells acquire a resistance to alecensa's effects.  Those cells can be radiated...

help Mom to continue using Alectinib. Thank you for the video list as well. Is there any experience or some period in which SBRT works, is it individual or are there...

Oh yes! SBRT (Stereotactic body radiation therapy) is a very focused type of radiation that is able to target and kill the tumor without the destruction of healthy tissue. The goal...

Hi again, thank you very much for the detailed response. I hope that SBRT will help my mom and that she will use Alecensa for a long time and after Alecensa...

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