One of the most common questions. we receive is why people are told that surgery isn't an appropriate option for metastatic disease. If you can see the areas where there is active cancer, why can't you just take it out?

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.

Here is the third and final case I discussed with two great experts in locally advanced NSCLC. Drs. George Blumenschein, medical oncologist from MD Anderson Cancer Center in Houston, and Wally Curran, radiation oncologist from Winship Cancer Center at Emory University in Atlanta, joined me several weeks ago to discuss a series of challenging cases that illustrate the complexities and array of options in treating patients with stage III NSCLC.

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).

Introduction to Locally Advanced NSCLC

Here's a webinar case discussion I did with Drs. Julie Brahmer from Johns Hopkins in Baltimore, and Greg Riely from Memorial Sloan Kettering Cancer Center in New York. They're great thoracic oncologists as wellas friends, and they were kind enough to join me for discussion of several complex cases that don't have clear answers and illustrate the reality that even when we know the evidence, there's plenty of room for judgment.

The subject of stereotactic lung radiotherapy (SBRT) for cure of stage I disease has been extensively covered on GRACE with good cause: we may be witnessing a major change in how we treat early stage cancer. Multiple strategies for improved surveillance are being developed, and hopefully one or more will be successful, resulting in more frequent detection of early stage disease. If so, we will have what my mentor calls a “delicious dilemma” – what is the best way to cure these early-stage patients?

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.

Dr. Quynh Le, radiation oncologist and Professor at Stanford University, was kind enough to participate in our NSCLC Patient Education Forum. She spoke on the topic of emerging treatment options using radiation for early stage NSCLC. The new work she's describing on stereotactic body radiation therapy (SBRT) is looking promising enough that it's being considered increasingly as a very strong choice for people with localized lung cancer but who aren't good candidates for surgery or are disinclined to pursue it.

Look, before I begin this post let me say that I’m really not trying to be a negative person when it comes to Avastin (bevacizumab; see here and here). It is a great drug in the appropriate setting, and is has been proven to prolong survival in first-line treatment of advanced NSCLC patients when combined with chemotherapy.