The Many Faces of Stage III NSCLC: Why We Have Such Trouble Nailing Down an Optimal Treatment for Locally Advanced Disease

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There are many open questions in managing lung cancer, but one of our historical areas that has been especially challenging has been locally advanced/stage III NSCLC, which we most commonly treat with at least two different forms of therapy, such as chemotherapy followed by surgery, chemo and radiation followed by surgery, or (most commonly) chemotherapy and radiation without surgery. Why is it such a controversial area?

Global differences: Shouldn't every curable patient have the right to the best treatment?

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One of the things we learn when studying the clinical research in lung cancer is that "global studies" often include patients with locally advanced (stage III) NSCLC along with those who have advanced (stage IV) NSCLC. Part of the confusion has been the ungainly status of stage IIIB NSCLC with a malignant pleural effusion -- historically termed "wet IIIB disease" -- in the IIIB camp but not having the curability of patients with "dry IIIB disease" --unresectable locally advanced NSCLC without a malignant pleural effusion.

Introduction to Locally Advanced, Unresectable Stage III NSCLC

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When I was a medical student, the question about lung cancer that was always asked on "the Boards" had to do with the difference between stage IIIA and stage IIIB non-small cell lung cancer (NSCLC). The reason this question was always asked is because patients with stage IIIA NSCLC might be considered for surgery, whereas patients with stage IIIB NSCLC would not be considered for surgery and instead would be treated with chemotherapy and radiation. The idea is that young doctors should be able to make that distinction and to direct patients to the appropriate specialist/treatment.

Locally Advanced NSCLC in the Frail/Elderly: Podcast of Case Discussion with Drs. Hesketh and Kelly

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Here is the second of three cases covering issues in managing elderly and frail patients with lung cancer that I discussed with experts Paul J. Hesketh from Lahey Clinic and Karen Kelly from Kansas University Medical Center. Both major experts in lung cancer, they have a lot of experience and have been leaders in publishing on the understudied population of elderly and poor performance status patients with lung cancer. This particular case covers treatment options for a patient with unresectable stage III non-small cell lung cancer (NSCLC).

Dr. Shirish Gadgeel on Managing Locally Advanced NSCLC

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Our next podcast slide presentation comes from Dr. Shirish Gadgeel, medical oncologist at Wayne State University in Detroit. He came out to Seattle for a physician education program I run and was kind enough to stay for our NSCLC Patient Education Forum, where he spoke on our Current Standards of Care for Locally Advanced (Stage III) NSCLC.

Here's his presentation in audio and video formats, along with the transcript and copies of the slides.

Managing Locally Advanced NSCLC: Summary from a Talk to Patients & Caregivers

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Here is the third portion of a talk I did at the Seattle-based non-profit Cancer Lifeline in May, and this section focuses on our current standards for managing unresectable locally advanced (stage III NSCLC). This covers theissues of sequential vs. concurrent chemo with radiation and the important issue of whether additional consolidation chemo after the radiation is feasible and advisable. It also covers the emerging key trials being done in this treatment setting.

Prophylactic Cranial Irradiation for Stage III NSCLC: Some Answers, Some Open Questions

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In my last few weeks as a GRACE guest faculty, I have been struck by the number of forum discussions that deal with brain metastases. Brain metastases are a growing problem in non-small cell lung cancer (NSCLC), as well as in multiple other cancers. Why is this? Twenty years ago, patients who developed brain metastases were usually at the end-stage of their cancer, with widely metastatic disease and few systemic treatment options. The prognosis for these patients was very poor, but not really because of the brain metastases.

Interview with Dr. Suresh Ramalingam: Current Standards and Controversies in Locally Advanced NSCLC

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Dr. Suresh Ramalingam is a longtime friend of mine and a national leader in the field of lung cancer. He is the Director of the Lung Cancer Program at the Winship Cancer Institute at Emory University in Atlanta, and he was kind enough to sit down with me to talk about his perspective on the current optimal treatment for patients with stage III, or locally advanced, NSCLC. We also spoke about managing metastatic disease, which will be covered in a separate podcast. It's an audio interview, but if people watch the video version, there are some figures synchronized with the discussion.