One of the core questions in managing patients with advanced non-small cell lung cancer is addressing the pace of the disease, because it can really vary a lot. In many cases, and in fact, in most cases of advanced non-small cell lung cancer, the cancer will be progressing at a rate at which you can see things getting worse if you don’t do treatment, over an interval of one or two months.
On the other hand, there are also some cancers that follow a more indolent or slow-growing pace, and in patients with a slow-growing cancer, especially if they don’t have symptoms clearly related to it, it might make sense to hold off on treatment for a longer period of time. So, it is worth asking a few central questions about how best to manage a patient with an indolent cancer, even if it is technically metastatic.
The first question is whether you see any progression at all over a period of, say, six or eight weeks, or maybe even longer, three or four months — because, if you’re not seeing progression over that period of time, it’s hard to have the real incentive to pursue a treatment that can have side effects. We don’t want the treatment to be worse than the disease. Again, if you do see progression at all, you need to ask whether it is clinically significant progression. Just being able to measure some degree of progression if you squint carefully — it is not necessarily enough to justify the side effects of treatment in somebody who is otherwise doing well, and may continue to feel well and do well for many months, or potentially many years, with a cancer that just happens to be quite slow-growing.
A second related question is: if you do see areas of clinically significant progression, is it really just one area that’s growing, or two, or is it multiple areas growing at once? Because, if you see just one or two areas growing, it might make sense to pursue a local therapy, something such as surgery or radiation. On the other hand, if you see multiple areas all growing together, it makes more sense to pursue a whole body, systemic therapy that can treat all these areas at once. But if you see just a single area growing, perhaps, even if it’s against a background of several other areas of known disease, if all of the other areas are growing at such a slow pace that you really don’t necessarily need to worry about them as a threat any time soon, it might make sense to just get the lead runner, to borrow a term in baseball, and address and neutralize the only area the really seems to be leading the charge as a threat.
And then, if we do see areas of multifocal progression, multiple areas growing at once, the leading consideration is going to be systemic therapy. If that’s the case, the leading question after that is: what is the best treatment to pursue — and that’s the subject of other videos here.