Clinical Approach for Unresectable Locally Advanced NSCLC - Episode 2
Jyoti Patel, MD:Patients with stage 3 disease should have a number of diagnostic tests at workup. Certainly, they should undergo CT of the chest with contrast to include the adrenal glands. Patients undergo a PET scan to look for distant disease. Unfortunately, a significant minority of these patients will also present with brain metastases. So, anyone with suspected stage 3 disease should undergo brain MRI. And then, importantly, patients should undergo pulmonary function tests. So, we should absolutely understand where patients’ pulmonary function is prior to initiation of therapy, even if we believe that they will not be surgical candidates. We get information from serum chemistry such as creatinine, which may help us adjudicate therapy, and then certainly any high ALK phosphatase or liver enzymes may make us look a little bit further for evidence in metastatic disease.
Although patients with stage 3 disease have potentially curative therapy, only the minority of these patients are disease free at 5 years, and current estimates are about 15% or 20% of these patients are disease free. So, not only are they at risk of recurrence of their primary disease within the first 2 years, which is quite substantial and up to 70% of patients will recur in that time frame, they’re also at risk of developing new primaries over time. And so, even after patients have been treated curatively, we continue to follow them with CT scans every year, even after 5 years.
All patients with lung cancer, I think, deserve multidisciplinary assessment. Certainly, we have made significant improvements in our understanding of the integration of chemotherapy in early-stage disease in patients who are resected as their primary therapy. In patients with stage 3 disease, this is probably the most controversial stage of disease. There are many reasonable algorithms with which to treat patients: chemotherapy followed by surgery followed by radiation, chemoradiation alone, or chemoradiation followed by surgery. So, certainly, this takes effort by radiologists, pathologists, pulmonologists, medical oncologists, radiation oncologists, and surgical oncologists.
We know that the best therapy is multilayered in these patients. And so, having adequate pathologic assessment, not only of all the mediastinal nodes but also markers that help, may guide therapy and predict response to therapy, as well as adjudicating the best treatment, whether that local therapy is radiation or surgery.
Transcript edited for clarity.