Lung Cancer.pdf

Implementation of Multidisciplinary Care 17
Non–Small Cell Lung Cancer
NSCLC is treated on the basis of the best clinical staging information
available prior to the initiation of definitive therapy. Survival depends on
the cumulative mechanical and biological effects of treatment on the primary
tumor and micro- and macrometastases. Despite our best efforts,
survival in patients with advanced-stage NSCLC remains dismal. Even in
patients with earlier-stage disease, survival rates are poor; 5-year survival
rates are about 55%, 50%, and 40%, respectively, for patients with stage IB,
IIA, and IIB disease. In selected patients, combinations of surgery,
chemotherapy, and radiation therapy may provide better survival results
than treatment with a single modality alone. The choice of initial therapy
(whether single-modality or multimodality therapy) depends on the patient’s
clinical stage at presentation and the availability of relevant clinical
trials. However, treatment options may vary even among different subsets
of patients with the same clinical disease stage.
Early-Stage Disease
In patients with early-stage NSCLC (stage I, II, or early IIIA T3N1),
treatment with surgery alone can result in long-term survival. Lobectomy
is the procedure of choice for lung cancer confined to a single lobe.
In certain patients with lung cancer and chest wall involvement
(T3N0M0), surgery alone as a local control modality may be an effective
treatment. En bloc resection of the lung and involved chest wall with
mediastinal lymphadenectomy results in a 5-year survival rate of approximately
50%. In addition, patients with T3N0M0 disease with tumors
less than 2 cm from the carina have a 5-year survival rate of 36%
with surgical resection alone.
Anatomic resection of lung cancer is the gold standard for treatment of
early-stage NSCLC. Lobectomy has been shown to be superior to lesser
resection even in patients with stage IA disease (T1N0) (Ginsberg and Rubinstein,
1995). Lesser resection, such as wedge resection or segmentectomy,
is reserved for patients in whom anatomic resection would carry a
prohibitive risk of complications. In patients unable to tolerate surgery, radiation
therapy can also be used as primary treatment. Potential complications
of radiation therapy include esophagitis and fatigue. Radiationinduced
myelitis of the spinal cord is devastating; the risk of this
complication can be minimized by careful administration of treatment.
Three-dimensional radiation therapy may further focus the dose on the
target area while minimizing radiation injury to surrounding tissues.
Preoperative radiation therapy has been investigated in clinical trials
and has been shown not to improve survival compared to surgery alone
(Komaki, 1985; Komaki et al, 1985).
The favorable results of trials of chemotherapy in patients with advanced-stage
disease suggest that chemotherapy may also improve sur-