CONTENT:

8.1 The Lung Cancer Treatment Multidisciplinary Team (MDT)
8.2 Treatment for Lung Cancer: Non Small Cell Lung Cancer (NSCLC)
8.2.1 Treatment for Lung Cancer Overview
8.2.2 Surgery
8.2.3 Radiation Therapy
8.2.4 Chemotherapy
8.2.5 Treatment of Late-Stage or Advanced NSCLC
i. Palliative Treatment for Lung Cancer
ii. Targeted Therapy for Lung Cancer

Forward to 8B Treatment of Small-Cell Lung Cancer . Back to 7D Staging of Small-Cell Lung Cancer .

Once my dog ate all my scrabble tiles. For days he kept leaving little messages around the house.

8.1 The Lung Cancer Treatment Multidisciplinary Team (MDT)

 
The ‘multidisciplinary‘ collaboration between pathologists, radiologists, physicians, surgeons, radiotherapists, cancer nurses and counselors is now well-established.  Each patient and each lung cancer will be assessed to select the most appropriate treatment. Each treatment for lung cancer option will have a way of removing or destroying lung cancer, but will also have side effects and possible complications. These will be explained to each patient.

Physicians (Oncologists) and Surgeons will work with recognized treatment guidelines, but all patients will be given information and treatment options by their clinicians.

Another important role for Multi-Disciplinary Teams (MDT’s) is in the development of local and national guidelines and protocols to optimize the use of available services and to standardize diagnostic and treatment approaches.

The MDT at each institution will use the guidelines from the American College of Chest Physicians (ACCP), European Society of Thoracic Surgeons (ESTS), and International Association for the Study of Lung cancer/American Thoracic Society/European Respiratory Society (IASLC/ATS/ERS) as the basis for developing and implementing their own diagnosis and treatment approach to the patient with lung cancer.

This is good. You become part of a team rather than struggling along alone.

Yes, and it has been said that individuals play the game, but teams beat the odds.

I’m liking the ‘multi-disciplinary’ bit very..shades of….hmmmmm.

8.2 Treatment of Non Small Cell Lung Cancer (NSCLC)

 
The diagnosis of Non-Small Cell Lung Cancer (NSCLC) will have been made by histology or cytology following detection of a lung tumor on imaging. NSCLC will be either adenocarcinoma or squamous cell carcinoma or large cell carcinoma.

8.2.1 Treatment Overview

 
The treatment for lung cancer options  differ for non small cell lung cancer (NSCLC), and for small cell lung cancer (SCLC). The choice of treatment for lung cancer  is based on the type of cancer (NSCLC versus SCLC) and the stage of the cancer (see Section 7).

There are three main treatment options for lung cancer: surgical resection, chemotherapy, and radiation therapy.

There are some new treatment options that include electrocautery, cryosurgery, laser surgery, photodynamic therapy, internally-administered radiation therapy and ‘targeted‘ drug therapy.

In addition to established treatments for NSCLC and small cell lung cancer, there are treatments that are more experimental. For advanced cancer that may have spread throughout the body, there are ‘palliative‘ treatments aimed at reducing symptoms, rather than curing lung cancer.

For advanced lung cancer, where the cancer cells express certain biomarkers, there are the newer forms of ‘targeted’ drug therapy.

Table 8.1  Treatment Overview for NSCLC
According to Stage

What is adjuvant and neo-adjuvant therapy?

Adjuvant means treatment given after the main treatment and neo-adjuvant means treatment given before the primary treatment.

I see. Adjuvant chemotherapy would be chemo given after surgery for example.

8.2.2 Surgery

 
Surgical removal of the lung tumor is performed for stages 1, 2, and 3 of Non-Small Cell Lung Cancer (NSCLC) and is performed ‘palliatively’ (to relieve symptoms) in stage 4 disease. Stage 1 and stage 2 NSCLC accounts for 30 % of cases; this proportion increases in screened populations.

Surgery is the definitive first-line treatment for lung cancer for stage 1 and 2 NSCLC, where there is no tumor involvement of the mediastinum.  The surgeon will retain as much normal functioning lung as possible. For this reason, lung function tests are performed before considering surgery, to assess how adequate lung function will be following tumor removal. Should this evaluation show that surgery will result in inadequate post-operative lung function, limited surgery or no surgery will be performed and, alternative treatment approaches will be considered.

The types of surgery will include the following:-

i. A wedge lung resection:

will preserve the most lung tissue and is recommended for small primary lung tumors, usually stage 0 or stage 1.

ii. A segmental lung resection:

includes more lung tissue and is recommended for stage 1 and stage 2 lung tumors.  A lymph node dissection (with frozen section evaluation) of hilar lymph nodes should confirm the N0 status of the clinical stage 1 malignancy before segmentectomy is performed. The presence of N1 involvement will result in a lobectomy in patients with adequate cardiopulmonary function.

Some small lesions are not amenable to segmentectomy due to their location: lobectomies are usually favored in such a scenario, although extended segmentectomies and bi-segmentectomies have been reported.

iii. A lobectomy:

completely removes one of the five lobes of the lung and is recommended for larger or more central tumors.

In patients with early-stage NSCLC, video-assisted thoracoscopic surgery (VATS) may be an alternative to an ‘open’ thoracotomy for patients undergoing lobectomy. VATS is a minimally-invasive approach to the treatment of early-stage NSCLC and is useful for those patients with significant medical comorbidity. Recent studies support the safety and efficacy of VATS lobectomy for patients with stage I NSCLC.

Local tumor ‘recurrence’ after surgery: for stage 1 and stage 2 tumors, is reported to be 23 % at five years (Kelsey et al, 2009).

iv. A pneumonectomy (or hemi-pneumonectomy):

involves the removal of the entire lung (either the left or the right lung) and is recommended for stage 2 NSCLC, but only in patients who have good reserve lung capacity.

v. ‘Positive’ surgical resection margins (R1):

means that the excised lung contains tumor involving the cut edge of the specimen and implies that some tumor has been left behind. These patients have a poorer prognosis than those with negative resection margins (R0), but post-operative radiation therapy may be required for this group of patients.

vi. Post-operative ‘surveillance:’

there have been no randomized clinical trials to compare different surveillance strategies for patients with NSCLC. The evidence from systematic reviews of the literature does not demonstrate a benefit. However, in most centers, following initial treatment, history, physical examination, and periodic chest CT imaging will be performed at clinic follow-up. The frequency of chest CT surveillance examinations will depend upon the risk of recurrence.

In 2004, the American Society of Clinical Oncology (ASCO) updated its recommendations for post-treatment surveillance in patients with NSCLC  (Pfister et al., 2004). History and physical examination is recommended for lung cancer patients who have been treated (with ‘curative intent’) and in the absence of symptoms, every 3 months during the first 2 years; the every 6 months through to year 5, and then annually.

If you have had, or are facing surgery for lung cancer remember, scars are just tattoos with better stories.

I’m going to get a grape tattoo. That way, when I’m old it will be a raisin.

8.2.3 Radiation Therapy

 
In patients with stage 1 or stage 2 NSCLC, who have limited lung capacity, radiation therapy alone may be used.

Patients who have a small primary tumor (< 5 cm) and impaired lung function or medical co-morbidity that prevents surgical resection or for those who refuse surgery, stereotactic body radiation therapy (SBRT) may be given. SBRT can only be given where the technical expertise is to do so is available. There are some other ‘ablative’ techniques such as radiofrequency ablation and cryoablation that are still experimental, but these may be offered in some cases.

For stage 3A NSCLC, surgery is usually the first-line treatment and may be combined with ‘adjuvant’ chemotherapy. But if surgery is not possible in stage 3A disease, chemoradiation treatment will be used.

In stage 3B NSCLC, chemoradiation may be the first-line treatment. Radiation therapy can be used as ‘palliative therapy’ to relieve symptoms when lung cancer invades tissues such as nerves or other structures in the chest.

Post-operative (or ‘adjuvant’) radiation therapy is used to prevent local recurrence following resection of NSCLC. Studies have shown that while post-operative radiation therapy can reduce the frequency of local tumor recurrence, it effects on overall survival (OS) is unclear.

Radiation therapy, nothing to worry about – a day without radiation is a day without sunshine.

8.2.4 Chemotherapy

 
Chemotherapy is used to treat stages 3 and 4 NSCLC and is also used as ‘adjuvant‘ therapy following surgery. The role of adjuvant’ chemotherapy is to destroy any cancer cells that may have been missed by surgery, or that may have metastasized.

Chemotherapy may sometimes be used as ‘neoadjuvant’ therapy, which is given before surgery.  The reason for using chemotherapy as a ‘neoadjuvant’ is to shrink the tumor so that the following surgery is more effective.

There are several chemotherapy regimens and combinations that are now used for NSCLC. The ‘standard of care’ is to use a platinum-based chemotherapeutic agent, especially for the treatment of advanced disease (stage 3 and stage 4).

Two platinum-based chemotherapy agents are used. The most common combination is cisplatin along with either an older (etoposide) or a newer chemotherapy agent, such as pemetrexed (Alimta), docetaxel, gemcitabine or vinorelbine.

Because NSCLC is not very sensitive to most chemotherapy drugs, chemotherapy alone is not considered to be a curative treatment (unlike the case for small cell lung cancer). This relative lack of chemosensitivity is why chemotherapy is combined with radiation therapy (‘chemoradiation therapy’) to treat advanced NSCLC. Chemotherapy is the main treatment used in stage 4 NSCLC.

I told my wife she was drawing her eyebrows too high. She looked surprised

8.2.5 Treatment of Late-Stage or Advanced NSCLC

 
In 2004, the American Society of Clinical Oncology (ASCO) updated their guidelines on the treatment for lung cancer of non-resectable NSCLC (Pfister et al., 2004). As part of ASCO’s review of previous studies and clinical data, the 2004 investigators found that the long-term survival for patients with non-resectable NSCLC was rare. But for patients who do achieve long-term survival, these patients have a high risk of a second primary lung cancer (estimated at 1% to 2% per year).

i. Palliative Treatment

 
In late-stage NSCLC, radiation therapy and surgery are used to relieve symptoms, such as pain, cough or hemoptysis; these treatments are not intended to be a cure nor may they improve patient survival.

Short courses of radiation therapy may also be given for patients who are not candidates for more aggressive therapy or who have very advanced-stage lung cancer, or for those who relapse following their initial treatment.

If you’re facing an ‘advanced stage’ diagnosis belief in your own recovery is essential, as is a good diet and lots of sleep.

Suits me. The only words I understand in the morning are, ‘go back to sleep’ and ‘bacon’.

ii. ‘Targeted’ Therapy

Treatment for stage 4 NSCLC may include a platinum-based chemotherapy agent and a non-platinum chemotherapy drug. A third treatment may be included, which is a ‘targeted’ therapy.

A targeted therapy may be a drug (such as a tyrosine kinase inhibitor or TKI), an antibody (a monoclonal antibody) or a protein that targets a particular cancer cell in order to inhibit the cancer cell’s growth.

The use of targeted therapy in stage 4 NSCLC, usually with a combination of two or more agents, may improve overall survival (OS) in some patients.

Table 8.2  ‘Targeted’ Therapy Options in Advanced-Stage
Non Small Cell Lung Cancer (NSCLC)

What do we want? Time travel. When do we want it? It’s irrelevant.

References

Kelsey CR, Marks LB, Hollis D et al. (2009). Local recurrence after surgery for early stage lung cancer: an 11-year experience with 975 patients. Cancer 115(22), 5218. . (Retrieved 26^th Feb 2015): https://www.ncbi.nlm.nih.gov/pubmed/19672942

Pfister DG, Johnson DH, Azzoli CG, et al. (2004). American Society of Clinical Oncology treatment of unresectable non–small-cell lung cancer guideline: Update. J Clin Oncol 22, 330-353. (Retrieved 27^th Feb 2015): http://jco.ascopubs.org/content/22/2/330.full.pdf+html
 

More references for this section are on this page .

Patient Information

NHS Choices Lung Cancer: Treatment (Retrieved 20 ^thApril 2015): http://www.nhs.uk/Conditions/Cancer-of-the-lung/Pages/Treatment.aspx

American Cancer Society Radiation therapy for non-small cell lung cancer. (Retrieved 3^rd May 2015): http://www.cancer.org/cancer/lungcancer-non-smallcell/detailedguide/non-small-cell-lung-cancer-treating-radiation-therapy
 

More patient information for this section is on this page .

Forward to 8B Treatment of Small-Cell Lung Cancer . Back to 7D Staging of Small-Cell Lung Cancer .