As I described in my last post, there is a strong consensus that overlapping chemotherapy (CT) and radiation therapy (RT) provides greater efficacy, meaning higher survival rates, than a sequential, non-overlapping approach for stage III, unresectable NSCLC. Beyond that, it’s a bit of a mess, with a wide range of choices and no clear “right” choice.

When I first started OncTalk, my first priority was to get some basic posts on the site that provided a quick and dirty assessment of the best standards we had for different stages of lung cancer. But not only did several of these gloss over a lot of material very quickly, that was really before I could add figures. I'm going to try to go over some issues that are on the site in a more thorough manner; how chemo and radiation concurrently became the preferred approach for stage III NSCLC is a good place to start.

After Avastin was found to produce a survival benefit when combined with chemo in advanced NSCLC, it became increasingly appealing to try to see if adding Avastin in earlier stages of lung cancer, both SCLC and NSCLC, where it might increase the cure rate.

In a previous post I described the open question about whether patients with locally advanced NSCLC should receive prophylactic cranial irradiation (PCI) after completing chemo and chest irradiation.

It's over, and I won (did you doubt me?).

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.

Immune-based approaches in lung cancer tend to generate significant buzz among patients and the general public, as well as in the media, but not as much optimism within the oncology world. Much of that is for good reason: while the concept of a minimally toxic, long-lasting anti-cancer approach like a vaccine is very appealing to all of us, oncologists have seen many hyped immune-based therapies deliver far less than their promise. This is for several reasons.

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 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.