It's only been in the past few years that we have begun to appreciate that there may be many different subgroups of patients who fit within the broader lung cancer population. We now have begun to see differences in the safety and/or activity of certain drugs in never-smokers vs. smokers, patients with adenocarcinomas (and especially bronchioloalveolar carcinoma, or BAC)vs. squamous cell carcinomas or other subtypes, and even in women compared with men.

For patients with locally advanced NSCLC, the question of whether to pursue a surgical or a non-surgical approach has a great deal to do with the extent of mediastinal (middle of the chest) lymph node involvement. The mediastinal nodes are shown here:

As I described in a prior post, pre-operative chemo and radiation are one very reasonable, aggressive option for stage IIIA NSCLC, particularly if the mediastinal lymph nodes involved are not large and there is only a single lymph node area involved.

As a medical oncologist, my primary role is to direct general management plans for many cancer patients and to develop chemotherapy and targeted therapy regimens. These regimens are sometimes directly administered through my office, and sometimes are coordinated with oncologists closer to a patient's home. The treatment is pretty much a cookbook approach, so it's really the same no matter who administers it.

As I noted in prior posts on the subject of unresectable stage III NSCLC, there is a general consensus that overlapping chemo and radiation is associated with better cure rates for this stage of locally advanced NSCLC than doing one followed by the other. At the same time, however, the overlapping, or concurrent chemo and radiation approach is associated with more challenges in terms of side effects, particularly esophagitis, as well as greater drops in blood counts, and potentially more inflammation in the lungs, or pneumonitis.

The oral EGFR inhibitors Iressa and Tarceva both have activity in advanced NSCLC, with proven responses in a minority of patients and improvements in cancer-related symptoms as well.

As described in a prior post, chemotherapy after surgery is often recommended after surgery, at least for a subset of patients with stage IB to IIIA (without mediastinal lymph node involvement) NSCLC, based on a potential to increase cure long-term survival compared to surgery alone.

Stage IIIA NSCLC, particularly with N2 lymph node involvement, is probably the NSCLC treatment setting that is most controversial. While it is the latest stage that we routinely consider surgery for, it is actively debated whether patients with stage IIIA NSCLC should have surgery or be treated with a combination of chemo and radiation without surgery.

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.