From the GRACE Archives | Originally Published March 17, 2012 | By Dr West
While the idea of staging a cancer is to get the best sense possible of the prognosis for a cancer and to define the best treatment approach for it, in reality it’s not uncommon for there to be ambiguity about the stage and the right treatment. Our goal is to provide the most treatment that will be helpful for a patient while also minimizing any excessive treatment that will confer more harmful than helpful effects. As an illustration, sometimes we’ll have a patient with a bulky, locally advanced non-small cell lung cancer that involves several mediastinal nodes, and there is a small nodule also in the lung opposite the one that contains the primary tumor, perhaps too small to reach and biopsy. Chemo and radiation together could possibly be curative if the smaller spot isn’t actually a metastatic lesion, but if it is, the concurrent multimodality approach, which is notoriously challenging, would likely not provide meaningful benefit compared with the difficulty of the treatment. Or in the case of many patients with bronchioloalveolar carcinoma (BAC), there may be a dominant lesion in one area, while in the background we see several very small nodules that may represent multifocal active cancer or just very small benign nodules that will never do anything (or something in between — one growing area and several lesions that may grow so slowly that they might reasonably be ignored).
In such ambiguous cases, it can be very helpful to test what happens with a cancer over time and treatment, and this information can often help refine the best treatment approach — letting us see how the biology of the cancer “declares itself”. For instance, in the case of a patient with a lung cancer that might possibly be curable with chemo/radiation concurrently, starting with chemotherapy and seeing what is happening with the cancer can guide us to feel more confident about pursuing the more aggressive approach if the cancer shrinks with chemo or at least hasn’t grown. On the other hand, if the cancer progresses after 2-4 cycles of chemotherapy, perhaps now with clear evidence of metastatic disease, that is an unfortunate result, but it has saved such a patient from undergoing a considerably more difficult treatment only to almost certainly experience the same result.
In the case of the patient with BAC, sometimes if a patient’s workup has taken more than 6 weeks, you can repeat a CT scan and see interval change in the background nodules over that time. Or by giving systemic therapy for a few months and checking results after that interval, we might see that those nodules remain unchanged, making us far more confident about the value of surgery for one growing lesion; if the other lesions are growing and/or new ones are appearing, it becomes clear that surgery isn’t a strategy that could be expected to be curative. It’s worth remembering that while post-operative chemotherapy is indicated to improve the probability of a patient with a higher risk resected cancer being cured after surgery, pre-operative chemotherapy can also provide comparable results.
In fact, in all sorts of cancer settings where the best treatment approach is ambiguous, starting with a good systemic therapy is typically a very good approach that burns no bridges and allows us to learn more about the pace of the cancer and its sensitivity to good treatment. These factors are critical in refining prognosis and helping to guide us in the recommendation for a management approach that won’t represent undertreatment or overtreatment.