Article and Video CATEGORIES

Cancer Journey

Search By

Dr. Jack West is a medical oncologist and thoracic oncology specialist who is the Founder and previously served as President & CEO, currently a member of the Board of Directors of the Global Resource for Advancing Cancer Education (GRACE)

 

Beyond Stage & Tumor Size: More Pathology Variables Associated with Risk of Recurrence after Surgery
Author
Howard (Jack) West, MD

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...

Next Previous link

Previous PostNext Post

Related Content

Article
Advance directives are a powerful way to take control of healthcare choices. These documents allow you to outline preferences for medical care and specify end-of-life wishes. These documents can also be a way to appoint loved ones who you would like to help with these decisions, such as a healthcare proxy (someone to make decisions on your behalf, if you cannot). As cancer treatments can involve aggressive treatments and/or complex medical management, having advance directives ensures that your desires regarding treatment options and end-of-life care are clearly communicated. 
Image
2024-25 patient perspectives header
Article
Tell your story and help us help others! Apply online now for this paid opportunity. This program gives a voice to those who have experience in participating in a clinical trial for a cancer diagnosis. Your voice helps to educate and advocate for others who are in or who may be considering a clinical trial.  We want to hear from you!
Image
Foro de Pacientes de Terapias Dirigidas de Cáncer de Pulmón
Video
¡El vídeo completo bajo demanda está disponible para verlo!

Forum Discussions

Hi elysianfields and welcome to Grace.  I'm sorry to hear about your father's progression. 

 

Unfortunately, lepto remains a difficult area to treat.  Recently FDA approved the combo Lazertinib and Amivantamab...

Hello Janine, thank you for your reply.

Do you happen to know whether it's common practice or if it's worth taking lazertinib without amivantamab? From all the articles I've come across...

Hi elysianfields,

 

That's not a question we can answer. It depends on the individual's health. I've linked the study comparing intravenous vs. IV infusions of the doublet lazertinib and amivantamab...

Recent Comments

JOIN THE CONVERSATION
I could not find any info on…
By JanineT GRACE … on
Hi elysianfields,

 

That's…
By JanineT GRACE … on
Hello Janine, thank you for…
By elysianfields on
EGFR
By happybluesun on