Radiation Therapy

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.

The last topic in our discussion of the evolving field of optimal treatment for locally advanced NSCLC is the potential role for induction chemotherapy before radiation, or, more commonly concurrent chemo/radiation (CT/RT).

My last post included studies that demonstrated no additional benefit from giving chemo after concurrent chemo/radiation for locally advanced NSCLC, but it's important to add a qualifier to that conclusion. The studies that have shown an overall favorable result from two cycles, or about 6-7 weeks, of chemo with radiation have thus far primarily been with cisplatin and not carboplatin.

Although consolidation taxotere after concurrent chemo and radiation therapy (CT/RT) emerged as the preferred treatment approach for about 2/3 of American oncologists over the last few years, this was predicated on an incomplete story. We received information from an additional two studies this year, and now it’s a big mess.

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.