I go to many meetings in which cases are presented and medical oncologists provide their repsonses about how they'd be inclined to treat a patient. Although we bemoan the lack of much progress in managing small cell lung cancer, one of the effects of that is that there is pretty strong uniformity in how we manage it, since the standards are quite well established.

To begin with, my overall impression is that the preponderance of evidence on adjuvant (post-operative) chemotherapy supports that it can reduce the recurrence risk and improve the survival at five years, which I'd presume to be pretty close to the "cure rate". The benefit isn't uniformly distributed for all patients: higher risk patients, as defined by stage and other additional factors like number of lymph nodes involved and the grade of the cancer, also matter.

In the last few years BAC has become increasingly studied and recognized as a distinct clinical subtype of lung cancer. The classic BAC syndrome is characterized by progression limited to the lungs, and its growth can be quite variable. The definition of BAC based on pathology has been applied pretty variably: although it should really be a non-invasive cancer that shouldn’t be able to spread outside of the lungs because it can’t invade into the bloodstream, most clinical trials now permit a combination of invasive adenocarcinoma with BAC features.

We’re recognizing more and more that lung cancer in never-smokers (LCINS) is a distinct disease, with different patterns of who gets it, how the cancer behaves, and it responds to treatments. But this recognition is still a work in progress, coming from a background in which the party line has been that NSCLC is treated the same regardless of the histologic type (squamous, adenocarcinoma, large cell, or other), smoking history, or other factors.

As I mentioned in another post, one of the first branch points in the decision tree about what I recommend as treatment for fit patients with previously untreated advanced NSCLC is the question of eligibility for avastin.

As I described in a recent post introducing the concept of the series, “What I really do”, I wanted to provide a summary of how interpret the evidence I show here, how I really approach real life patients. Some of this will illustrate that the experts don’t agree 100%, and that we all add some interpretation and style to how we manage patients. What I describe isn’t meant to be a dogmatic declaration of what everyone should do, but just the way I apply the evidence from trials of somewhat selected patients in the real world.

Over the past few years, the role of post-operative, also known as adjuvant, chemo has become increasingly accepted as a standard of care. Several trials have shown an improvement in survival at about 5 years that is in the 5-15% range for recipients of chemo.

One topic that is rarely considered in the management of SCLC is the role of surgery. The main reason is that the vast majority of patients presenting with SCLC either have extensive disease that has spread throughout the body (2/3 of SCLC presentations) or at least already have rather bulky nodal disease that would make then a less-than-ideal candidate for surgery even if they had NSCLC; the other key component of this bias against surgery is the strong tendency for SCLC to have micrometastatic disease even early in the disease process.

In the past couple of posts we’ve seen that based on evidence from Japan and Rome, number of lymph nodes resected and also the absolute number of positive nodes and/or proportion of positive nodes may be important prognostic variable. A third abstract I reviewed on the same subject came from Peoria, IL, and illustrated a key reason why using these variables may not be as consistently useful as we’d like, at least in many parts of the world.

In the last post I discussed some interesting work from a group in Japan that suggested that the number of lymph nodes that are removed and positive for NSCLC may be a very important prognostic variable, potentially an even more important factor than location of the nodes, which is the basis for how we stage nodal involvement in NSCLC now.