This audio interview by medical oncologist Dr. Jack West of radiation oncologist and lung cancer expert Dr. Vivek Mehta covers the current and emerging treatment options for radiation alternatives to treat early stage non-small cell lung cancer (NSCLC).
The setting of unresectable, stage IIIA or IIIB NSCLC (without a malignant pleural effusion) is currently one for which what we feel is best for the patient isn't necessarily something for which we have good evidence. For fit patients, there is a strong consensus that giving concurrent chemo with radiation provides a modestly but consistently higher cure rate than giving chemo and radiation sequentially. But that concurrent chemoradiation plan lasts for only 6-8 weeks, but whether there's more we should be doing, or what we should do, is entirely unclear.
As a follow-up to my last post on the appeal of developing new regimens for combining with radiation in treatment of locally advanced unresectable NSCLC, I wanted to highlight work being done by the Cancer and Leukemia Group B (CALBG), one of the major cancer cooperative research groups in the US.
While there have been new agents introduced and rapidly changing standards in advanced NSCLC, another 40% of patients with NSCLC have locally advanced (stage III) NSCLC, many of whom with disease that is not resectable but is potentially curable with agressive chemo and radiation.
Here's a situation in which I learned something from the questions raised by people here online. A handful of people with extensive disease small cell lung cancer (ED-SCLC) in the last year or two have mentioned receiving radiation for areas of residual apparent disease after receiving initial chemotherapy. I had noted that I had never done this and didn't really see a clear rationale for pursuing a local treatment like radiation for a disease that has already declared itself as spreading throughout the body.
The standard of care for at least stage I and II NSCLC is surgery, sometimes followed by chemotherapy. We know, however, that not every patient who presents with early stage NSCLC is healthy enough to pursue surgery, whether due to general age-related or other illnesses, or due specifically to a low pulmonary reserves, usually from years of smoking.
In a very recent post I provided an introduction to the special case in NSCLC known as a Pancoast tumor, including a historical perspective of how it has evolved from being perceived initially as an untreatable, uniformly fatal diagnosis to a cancer that could be cured with radiation and then surgery in a significant minority of patients (35% in one large series).
One subtype of lung cancer that we haven’t specifically talked about is called a Pancoast tumor, named for the doctor who first described them. A Pancoast tumor is a NSCLC that is located in a groove called the superior sulcus (Pancoast tumors are also sometimes referred to as superior sulcus tumors), at the top (or apex) of each of the lungs. Here's the appearance of one on a chest x-ray:
Despite the fact that a very significant proportion of the "real world" patients have considerable medical problems such as markedly decreased lung function (pretty common with many years of smoking), weight loss (5 or 10% of body weight is usually considered a problem), or otherwise are not able to be very active.
As a follow-up to my last post and an end to this extended discusison of locally advanced NSCLC before moving to other topics, I'll just cover some more recent work on the topic of chemo followed by chemo and radiation for stage III NSCLC. In that post, I showed that over the past several years, we hadn't seen the promise of this induction strategy in small trials translate into especially favorable results in larger multicenter trials.