This is my first post on this wonderful site.

Recently I saw a patient who had undergone surgery for stage II Non-Small Cell Lung Cancer and was receiving chemotherapy with another cancer doctor. He came to me for a second opinion. Among the questions he had was what tests should he get after completing all his treatment.

As a conclusion to the string of posts on the topic of lymph nodes removed at the time of surgery, I wanted to touch on the issue of what our representative experience is in the US, because I described the results of specialized centers in Japan and Italy that typically yielded large numbers of lymph nodes, often more than 10.

I think one of the most important lead stories from ASCO 2008 got buried. Nobody's really talking about it yet, but they should.

I was reminded of the important topic of occult N2 NSCLC by a comprehensive review that just came out in the Journal of Thoracic Oncology (abstract here) by a friend, thoracic surgeon Frank Detterbeck, who leads the thoracic oncology program at Yale.

Several users on a recent thread have raised questions about whether exercise after surgery or chemo and radiation is harmful, beneficial, or has no effect on outcomes among people with lung cancer. Unfortunately, this field has so few answers that it's easy to imagine doctors filling in the void with half-truths or less. I explained that I had seen so little information on this subject that I couldn't shed much light, but I'd try to dig up some information.

While the differences in anticipated clinical benefits from EGFR tyrosine kinase inhibitors like tarceva and iressa are well known (summarized in prior post), less well appreciated is the potentially significant differences in results with garden variety standard chemotherapy.

People who have been following my comments know that I am often questioning the wisdom of surgery in patients who don't fit the usual criteria for resection, which is most commonly pursued in stage I and II NSCLC and is often considered an option for some patients with stage IIIA NSCLC. To provide a very quick review of NSCLC staging, it's a combination of three factors:

1) Tumor (T) stage -- from 1 to 4, going from smallest and easiest to remove to hardest or largest to remove

2) Node (N) stage -- from 0 to 3, going from none to further distances from the main tumor

Many of us who work in the field of lung cancer, whether as doctor, patient, friend, or family member, bemoan that lung cancer is too often viewed as a black sheep among cancers – little attention and too few resources. But one of the key ways in which lung cancer has lagged behind has been in terms of clinical trials participation, and this is something that we can control, and our underperformance (on both the physician and patient side) has hurt the field.

Intuitively, you'd think that people who are doing worse while getting treated for lung cancer are not going to do as well as people who have improvement in their symptoms after treatment starts. But how much do patient symptoms count in our current medical system for deciding whether a treatment is working or not, and when to move to a new therapy? The answer is that patient reported symptoms don't have a clear role yet.

There's a website called Adjuvant! Online, developed by oncologist Peter Ravdin, that is best known for its use after surgery for breast cancer in assessing the value of post-operative chemo. Because I don't really treat breast cancer, I haven't spent time on the website, but I do know that it's a valued resource among practicing oncologists who care for patients with breast cancer.