I've covered stage IIIA NSCLC in several prior posts, mentioning that it's a clinical setting that is among the most controversial, but I don't think I've really described my real world approach. To review, the controversy is that for stage IIIA NSCLC with mediastinal lymph node involvement on the same side as the tumor (N2 nodes), some people would recommend surgery as a main treatment strategy, and others would recommend chemo and radiation without surgery.

Most of what I write about here highlights the evidence supporting treatments, and that’s certainly how we strive to practice oncology. But the reality is that patients and doctors often find themselves in the middle of settings where we don’t have any answers and need to rely on judgment, or we think we can potentially do better by defying conventional wisdom. Doctors lie all along the spectrum of being “data-driven” on one end and being a “cowboy” on the other end.

Though EGFR inhibitors like tarceva can produce some terrific and long-lasting results in many patients, they aren't toxicity-free. The "targeted therapies" we use just have a very different side effect profile from standard chemo, and the EGFR inhibitors are well known to have skin-related side effects as the leading problem, with loose stools/diarrhea as a less nearly ubiquitous second place issue.

The general approach to NSCLC is in transition right now, as the line between first and second line therapy are becoming increasingly blurred. A few years ago, the clear standard was that we usually stop first line chemo after four to six cycles, then follow a patient clinically and radiographically until they show evidence of progression, at which time we’d start second line treatment.

The treatment of relapsed SCLC isn’t especially controversial, because this is an area where there aren’t enough breakthroughs. In someone fit enough to perform their own activities of daily living and getting out of the house, the main question is how long it has been since they completed their first line treatment.

One of the topics that frequently occurs in the clinic, and that patients often ask about, is the situation in which there is some suggestion of slight progression. This can take the form of many different situations: a rising tumor marker (see

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.

I doubt there is a group of lung cancer patients more common but less well studied than the substantial subset of frail and/or very elderly patients with advanced NSCLC. While “elderly” patients, usually defined as age 70, have been evaluated as a subset of the population in larger studies and even been the subject of specific studies just for the elderly, most of this work has shown that fit elderly patients do as well as younger patients getting the same aggressive treatment.

I go to many meetings in which cases are presented and medical oncologists provide their repsonses about how they'd be inclined to treat a patient. Although we bemoan the lack of much progress in managing small cell lung cancer, one of the effects of that is that there is pretty strong uniformity in how we manage it, since the standards are quite well established.

To begin with, my overall impression is that the preponderance of evidence on adjuvant (post-operative) chemotherapy supports that it can reduce the recurrence risk and improve the survival at five years, which I'd presume to be pretty close to the "cure rate". The benefit isn't uniformly distributed for all patients: higher risk patients, as defined by stage and other additional factors like number of lymph nodes involved and the grade of the cancer, also matter.