Radiation Therapy

Ask and ye shall receive! The leading requiest for a video podcast presentation was for a summary of the subject of locally advanced, unresectable stage III NSCLC. Here you go:

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Sorry it's a little rushed, but it's a struggle to do a topic justice with a 10 minute limit (the most YouTube accepts). In the future, we'll try to divide bigger topics into two podcasts if it's going to require cramming into a 10 minute interval. It may help for you to have the images and transcript available, so here they are:

One of the issues that we've commonly discussed and debated here is the question of when a local approach like surgery and/or radaition may be appropriate for I recently saw a patient of mine who I first met more than four years ago. At that time, he was only 37 years old and had just been diagnosed with stage IIIA NSCLC with several N2 nodes involved, after having quit smoking a couple of years earlier. He had actually initiated treatment with another local oncologist, a plan of chest radiation along with concurrent weekly carbo and taxol.

In prior posts I've described the special circumstance of a Pancoast tumor, which is a tumor at the top of the lung that tends to grow into the spine, ribs, and sometimes the nerves going to the arm. These cases are a major challenge because surgery is often something to consider, because they often grow locally more than speading to the rest of the body, but surgery can be a special challenge because the vertebrae are generally not considered to be resectable.

This audio interview by medical oncologist Dr. Jack West of radiation oncologist and lung cancer expert Dr. Vivek Mehta covers the current and emerging treatment options for radiation alternatives to treat early stage non-small cell lung cancer (NSCLC).

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.

As a follow-up to my last post on the appeal of developing new regimens for combining with radiation in treatment of locally advanced unresectable NSCLC, I wanted to highlight work being done by the Cancer and Leukemia Group B (CALBG), one of the major cancer cooperative research groups in the US.

While there have been new agents introduced and rapidly changing standards in advanced NSCLC, another 40% of patients with NSCLC have locally advanced (stage III) NSCLC, many of whom with disease that is not resectable but is potentially curable with agressive chemo and radiation.

Here's a situation in which I learned something from the questions raised by people here online. A handful of people with extensive disease small cell lung cancer (ED-SCLC) in the last year or two have mentioned receiving radiation for areas of residual apparent disease after receiving initial chemotherapy. I had noted that I had never done this and didn't really see a clear rationale for pursuing a local treatment like radiation for a disease that has already declared itself as spreading throughout the body.

The standard of care for at least stage I and II NSCLC is surgery, sometimes followed by chemotherapy. We know, however, that not every patient who presents with early stage NSCLC is healthy enough to pursue surgery, whether due to general age-related or other illnesses, or due specifically to a low pulmonary reserves, usually from years of smoking.

In a very recent post I provided an introduction to the special case in NSCLC known as a Pancoast tumor, including a historical perspective of how it has evolved from being perceived initially as an untreatable, uniformly fatal diagnosis to a cancer that could be cured with radiation and then surgery in a significant minority of patients (35% in one large series).