Before turning back to brain metastases, I wanted to cover a topic that has generated some recent questions, and that is the issue of potential interactions of tarceva with food and other drugs. Just as an introduction, the standard dose of single-agent tarceva in lung cancer is 150 mg by mouth daily, and this is meant to be taken on an empty stomach, at least one-hour before or two hours after eating.

Celecoxib (Celebrex) has been studied in combination with chemo for NSCLC and has generated enough promising results to raise expectations but also enough negative data to produce disappointment. Dr.

We'll break from brain metastases for a while to talk about another potential avenue of targeted therapy in lung cancer: the cyclo-oxygenase, or COX, pathway.

While brain metastases are common, some patients seem to be at higher risk than others. As previously noted, SCLC has a very high risk of spread to the brain. For NSCLC subtypes, several studies have shown that patients with non-squamous lung cancers have a greater tendency to develop brain metastases than those with squamous cancers, which tend toward more local spread.

I'm going to cover the general concepts of management of brain metastases, a subject that is still evolving because of our growing technology, particularly with stereotactic radiosurgery (SRS), commonly referred to as gamma knife. In many cases, our practice has moved a bit ahead of the data. We'll start with some general issues and then, over several posts, cover issues from surgery to radiation to medical therapy.

The notorious and always welcomed words after surgery are, "we got it all", providing great relief to the patients and families who hear the phrase. We know that surgeons can take out all identifiable disease that they see when they do surgery, and that there is no evidence of visible disease on CT scans or on newer imaging techniques like PET scans. But why do we see that approximately 30% of patients with stage I NSCLC or about 50% of patients with stage II NSCLC recur?

Most of the focus on predicting response to EGFR inhibitors has been on identifing molecular markers that are associated with major response to this kind of treatment. But we know that there is a group of patients who get no benefit from these expensive drugs, and in these patients, EGFR inhibitors would just lead to side effects and keep them from a potentially more effective therapy for them.

There is still plenty of active debate about whether patients with stage III NSCLC who have mediastinal lymph nodes, the ones in the middle of the chest between the lungs but on the same side as the main tumor, should receive surgery in some circumstances or not.

Historically, surgery for lung cancer has been through an open thoracotomy (thorax = chest; otomy = cutting/slicing), which involves a long incision around the side of the chest, removal of ribs, and spreading of the remaining ribs to get a good view of the area of the operation. Even with the most skilled surgeons, it's a procedure that is rigorous for a patient to get through and has a recovery period typically of weeks.

In most of the history of lung cancer management, we have been "lumpers" rather than "splitters", tossing together many different kinds of lung cancer together and presuming that they all respond similarly and should be treated similarly.