Dr. Mark Socinski, University of Pittsburgh Medical Center, compares the use of chemotherapy to chemo/radiation in the preoperative setting in stage IIIA lung cancer.

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As I previously mentioned, the role of surgery in stage IIIA disease remains controversial, although there are many patents who are suitable candidates for this, and for whom this approach is a very reasonable approach. One of the questions that is often raised in this situation is: what type of treatment should the patient receive prior to going into the operating room? As I previously mentioned, if you document N2 disease, and in this case IIIA disease, going to the operating room should not be the initial therapeutic approach in these patients, and we generally believe that they need preoperative therapy. The two choices are chemotherapy alone, versus chemoradiation.

We actually have no good data to guide us in this way — both approaches seem to be reasonable, both approaches are backed by previous trials addressing these sorts of things. One of the issues with regard to chemoradiation is that one has to be careful about the dose in the field of radiation, as well as the timing of surgery, following this to avoid postoperative complications that can be difficult to manage in the postoperative setting.

Obviously with chemotherapy alone, you don’t have the risks of radiotherapy. There is some evidence to suggest that, perhaps, chemoradiation may improve local/regional control relative to chemotherapy; it may increase the rate of what we call downstaging, which we think is a positive prognostic thing. What I mean by downstaging is, if you know the lymph nodes are positive at the time of initial diagnosis, if you employ chemotherapy or chemoradiation at the time of surgical resection, those lymph nodes that were positive pretreatment are now negative, so the chemotherapy and chemoradiation had an effect. We tend to see higher downstaging rates with chemoradiation, and downstaging has been associated with improved survival in this population, so that might argue for preoperative chemoradiation as a more reasonable strategy, but the data is not entirely clear in this regard.

One thing I will say is that, whether it’s preoperative chemotherapy, or preoperative chemo/radiotherapy, the surgeon involved should be involved right from the beginning. He or she should be an experienced surgeon that does this quite often, so they know how to manage patients both prior to the operation, intraoperatively, as well as postoperatively to minimize the risk of some of the complications such as ARDS, volume overload, postoperative infections and arrhythmias, and those sorts of things really should be managed in experienced hands from the thoracic surgeon point of view.