Lung Cancer.pdf

120 S.G. Swisher
Treatment Options for Locally Advanced
Non–Small Cell Lung Cancer
The first thing to realize when treating patients with locally advanced
NSCLC is that this category includes a wide variety of manifestations of
disease (see the lung cancer staging system, which appears in chapter 1).
Although all these different types of tumors are lumped together as
stage III disease, some tumors within this group are best treated with
surgery, and others are best treated without surgery (Table 7–1). The
critical task from the clinician’s standpoint is to recognize the different
subsets so that appropriate multidisciplinary care can be tailored to the
individual patient.
In deciding how to treat locally advanced NSCLC, it is helpful to consider
the advantages and limitations of each of the conventional modalities
of treatment—surgery, radiation therapy, and chemotherapy. Surgery
and radiation therapy address primarily local-regional disease, while
chemotherapy treats primarily systemic disease but has some local-regional
effect.
Although surgery is probably more effective than radiation therapy in
controlling local-regional disease, surgery is associated with increased morbidity
and mortality and requires removal of noninvolved lung parenchyma.
The benefit from the increased local-regional control afforded by surgery
must therefore be balanced against the increased morbidity of the operation.
Furthermore, if the disease is advanced, in which case systemic recurrence is
more likely, less emphasis may need to be placed on local-regional control,
and radiation therapy may be preferable to surgery for control of the primary
tumor.
Even though many patients with locally advanced NSCLC have micrometastatic
disease at presentation and ultimately develop metastatic
disease, adequate local-regional control still has an effect on long-term
survival. Kubota et al demonstrated in a randomized trial that patients
with stage III disease treated with chemotherapy alone had far lower survival
rates than patients treated with chemotherapy and radiation therapy
because of the lack of local-regional control (Kubota et al, 1994).
Chemotherapy is aimed primarily at distant disease but in many instances
can help improve local-regional control by sensitizing tumors to
radiation (radiation-sensitizing chemotherapy) or downstaging tumors
prior to surgery. Various studies have demonstrated improved survival
with the addition of chemotherapy to radiation therapy (Schaake-Koning
et al, 1992; Dillman et al, 1996; Sause et al, 2000) or surgery (Roth et al,
1998; Rosell et al, 1999).
Stage III disease is heterogeneous because in some subsets within this
group long-term survival is dependent on local-regional control while in
other subsets long-term survival is primarily dependent on control of dis-