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)

 

Current State of the Art for Unresectable Locally Advanced NSCLC
Author
Howard (Jack) West, MD

Locally advanced, or stage III, NSCLC, can potentially include patients for whom surgery is an option, but for many patients with stage IIIA and a majority of those with stage IIIB NSCLC, a non-surgical approach is the best treatment recommendation. It's important to keep in mind that the goal of treatment for patients with locally advanced NSCLC but who don't have a malignant pleural effusion (fluid inside the chest but outside of the lung, with cancer cells in it) can potentially be cured. The risk of doing poorly are from both local growth and distant micrometastatic spread (living cancer cells traveling elsewhere in the body through the bloodstream).

The old standard in the 1980s was radiation alone. An important clinical trial the "Dillman Trial" then compared the old standard of just radiation alone to chemo with a two drug combination of "cisplatin-based" chemo for two cycles followed by the same radiation plan. The cure rate was significantly better, although unfortunately we were still curing these patients far too rarely. However, it changed the standard of care from radiation alone to a combination of chemo and radiation together.

Over the last decade, the more timely question has been how best to combine chemo and radiation. Multiple trials from different countries have tested chemo and radiation given one at a time ("sequential chemoradiation", as was done in the Dillman trial) to chemo and radiation given together ("concurrent chemoradation"). The vast majority of these studies have shown that concurrent chemo and radiation is associated with better chances for cure, at a cost of greater short-term toxicity during and shortly after treatment. The leading side effect problems with this approach are severe esophagitis, or burning/irritation of the esophagus that can make it very painful to swallow, and pneumonitis, which is inflammation of the lung tissue.

Patients with significant medical problems, particularly very compromised lung function, as well as patients with large tumors that would require very large radiation fields, are potentially not well served by this approach and may do better to receive sequential therapy, or possibly chemo alone to shrink the cancer somewhat so that the radiation field may be smaller. In general, stage III NSCLC is an area where the toxicity of treatment, and even the potential for dying from the challenging treatment, can limit the feasibility and potential benefit of a very aggressive approach.

Some physicians and centers routinely chemo and radiation together, followed by additional and often different chemo alone (generally docetaxel, or Taxotere). This is based on very encouraging early work by the Southwest Oncology Group (SWOG) that showed remarkably good results from a cisplatin-based doublet chemo (cisplatin/etoposide) with radiation followed by three cycles of taxotere. This is still controversial, since it can be very challenging to get patients through this approach safely, and the patients enrolled on this trial were unusually fit, not representative of a more general population of patients with marginal lung function and significant other medical problems. We still await further trials to clarify whether this approach is ideal. Other doctors commonly give carboplatin-based chemo on a weekly basis with radiation, but I don't favor this approach as much, since our results tend to be a bit better with cisplatin than with carboplatin, and we don't have as much evidence as we would like that carboplatin gives as good results. And the stakes are high, so we don't want to cut the chances of cure even slightly if we don't have to. We just need to balance that against the very real safety risks.

Current trials are focusing on newer chemo in this mix, adding targeted therapies to potentially improve cure, and adding prophylactic brain radiation after everything else. The last is an important ongoing question because we see a distressingly high rate of relapses in the brain first or brain only after all of the other treatment, presumably because the central nervous system acts as a "sanctuary site" where chemo cannot easily penetrate and fight micrometastatic disease. However, we still don't know that brain radiation is appropriate here, so I don't recommend it in this setting outside of a clinical trial. Together, the improvements in our treatment plans have led to significant gains in our cure rate for stage III NSCLC over the past 20 years, but we still need to build on this momentum.

Next Previous link

Previous PostNext Post

Related Content

Image
Bladder Cancer Video Library 2024
Video
Dr. Petros Grivas discusses intravesical treatment for patients with nonmuscle invasive, or early-stage, bladder cancer, the importance of participating in clinical trials for bladder cancer, combination therapy options for patients with metastatic or incurable bladder cancer, and the importance of family history of cancer and discussing that history with your doctor.
Image
Case Based Panel
Video
The panel discusses treatment options for a patient diagnosed with EGFR Exon 19 Deletion NSCLC and examines data from the Laura Trial, a patient with a smoking history and diagnosis of small cell lung cancer, and how the Adriatic Study factors into decisions, and a patient with NSCLC adenocarcinoma, and a EGFR Exon 21 L858R Alteration, and how data from the Flaura 2 Trial can impact treatment decisions.
Image
Terapias Dirigidas de Cancer de Pulmón 2024
Video
La Dra. Estelamari Rodríguez presenta información básica sobre el NSCLC EGFR+ y analiza la importancia de las pruebas de biomarcadores en el cáncer de pulmón y ofrece una descripción general de las opciones de tratamiento para la enfermedad EGFR+.  Para ver la playlist completa, de click aquí.        

Forum Discussions

Hello Linda, my name is Alexandra Beneke, I'm the Outreach Manager for GRACE. Your willingness to share your experiences and knowledge with the cancer community is truly inspiring. Your dedication to...

Hi Bluebird,  Welcome to GRACE.  I'm sorry you're going through this scare and hope it's just inflammation or from an infection you didn't know you had. 

 

A CT would be...

Radiation + Brain Operation has just been discarded due to high risk. They will double Tagrisso dosis and then wait to see if it works, then try traditional Chemo. I would...

Hi and welcome to GRACE.  I'm sorry to know you are entering a new stage.  I'm not about to comment just now but wanted to let you know I see your...

Edit to say, we can't give advice but we can comment with views and facts.  :)

 

My first thought is to ask if she has been seen at a large...

Hi Barbro, Welcome to GRACE. I'm sorry you're worrying about this. We aren't able to give feedback on scan reports. Interpreting scan reports in this setting is not only unethical but...

Recent Comments

JOIN THE CONVERSATION
Tagrix FDA Approval
By mariachristian on
Hi Judy! It is so good to…
By JanineT GRACE … on
Tagrix vs Tagrisso
By Dipakchavan on
Hello Linda, my name is…
By AlexandraGBeneke on