Episode 026: Lung Cancer Series, Pt. 4: Treatment of early stage NSCLC
The Fellow on Call: The Heme/Onc Podcast
What Are the High Yield Facts to Know?
The key thing here is that the surgeons try to get at least a two centimeter margin. Vevi, how does that change anything though? So let's say this, this gentleman did have our one or our two diseases. I suspect that that could suggest that his cancer has a higher risk of coming back. In those cases, we will want to re resect these patients.
How do we think about treatment of lung cancer?
Recap on staging (see Episode 025)
* Pro-tip: Highly recommend that you “forget” about the actual staging and focus more on the individual T, N, and M status
* Tumor size:
**T1a <1 cm
**T1b <2 cm
**T1c <3 cm
**T2a <4 cm
**T2b <5 cm
**T3 5-7 cm
**T4 cm
*Nodal status:
**Double digit nodes = hilar or intrapulmonary (peripheral) = N1
**Single digit nodes = mediastinal (central ) = N2
**Contralateral nodes or supraclavicular = N3
*Sites of metastatic disease
Approach to treatment in a stepwise approach:
*Goal: Whenever feasible, we want to consider getting the patient to surgery to remove the cancer.
*Surgery or no surgery?
**How do we decide if someone is appropriate for surgery:
***Do they want surgery?
***Do they have the pulmonary reserve if they were to get surgery ?
***Do they have the cardiac reserve to withstand surgery?
***Is the tumor size too big? (Usually >7cm)
***Is the tumor invading other structures?
****If invading other structures, surgery may not be possible; highly consider tumor board discussion
***Mediastinal lymph node involvement?
****Central lymph node involvement usually requires definitive chemotherapy + radiation (not surgery up-front)
***Supraclavicular lymph node or contralateral lymph node?
****This would be treated with chemotherapy and radiation
Speaking of surgery, what are the options for types of surgeries for lung cancer?
*Sub-lobar:
**Wedge (smallest resection)
**Segmentecomy - ideally we want to do at least a segmentectomy
*Lobar resection:
**Lobectomy
**Pneumonectomy
What if a patient’s tumor is amenable to surgery, but the patient’s underlying co-morbid conditions preclude him from getting a surgical intervention?
*This is where we consider using radiation for treatment, specifically Stereotactic body radiation therapy (SBRT)
Characteristics of surgical report?
*The “R” status is if there is residual tumor after the surgery. This is a combination of evaluation by a pathologist AND by gross inspection by the surgeon
**R0: No evidence of disease
**R1: Microscopic sites of disease
**R2: Macroscopic sites of disease (visible tumor)
*Why does this matter?
**If there is residual disease, there may be a role for further resection and/or systemic therapy
*When a tumor is >4cm, patients are higher risk for recurrence, even without nodal disease or metastatic disease. We will give these patients chemotherapy in the adjuvant setting.
Approach to adjuvant chemotherapy:
*In NSCLC, it is often a two-drug regimen, including a platinum-based therapy
*Cisplatin is important
**Based on LACE Pooled Analysis (https://ascopubs.org/doi/10.1200/jco.2007.13.9030)
***Cisplatin-based adjuvant therapy vs. placebo showed >5% improvement in survival when using cisplatin-based therapy
***For adenocarcinoma:
****Give cisplatin with pemetrexed
****ALWAYS start patient on B12 and folate at least 1 week before starting pemetrexed and continue this throughout treatment, up to and including 3 weeks after their treatment course
***For squamous cell caricnoma:
****Give cisplatin with gemcitabine OR docetaxol (taxotere)
*Nodal involvement (N1): Give two-drug regimen, as noted above
*Additions to two-drug regimen:
**IMPOWER 010 Trial: In patients with PDL1 >50%, patients did better with 1 year of immunotherapy (atezolizumab) after adjuvant therapy (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02098-5/fulltext; https://ascopost.com/issues/november-10-2021/impower010-adjuvant-atezolizumab-improves-disease-free-survival-and-nsclc-relapse-in-patients-whose-tumors-express-pd-l1/)
**Mutations matter! ADAURA Trial: EGFR with exon 19 deletion or L858R can get osimertinib, which had an improved outcomes (https://www.nejm.org/doi/full/10.1056/NEJMoa2027071)
References:
https://ascopubs.org/doi/10.1200/jco.2007.13.9030 - LACE Pooled analysis
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02098-5/fulltext - IMPOWER 010 Trial
https://www.nejm.org/doi/full/10.1056/NEJMoa2027071- ADAURA Trial
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