Non-Small Cell Lung Cancer Professional Information

STAGE IIIB NON-SMALL CELL LUNG CANCER

Patients with stage IIIb non-small cell lung cancer (NSCLC) do not benefit from surgery alone and are best managed by initial chemotherapy, chemotherapy plus radiation therapy, or radiation therapy alone, depending on sites of tumor involvement and performance status. Most patients with excellent performance status should be considered for combined modality therapy. However, patients with malignant pleural effusion are rarely candidates for radiation therapy, and should generally be treated similarly to stage IV patients (see separate section of this summary on treatment of stage IV disease). Many randomized studies of unresectable patients with stage III NSCLC show that treatment with neoadjuvant or concurrent cisplatin-based chemotherapy and chest irradiation is associated with improved survival compared to treatment with radiation therapy alone.[1-5] A meta-analysis of patient data from 11 randomized clinical trials showed that cisplatin-based combinations plus radiation therapy resulted in 10% reduction in the risk of death compared with radiation therapy alone.[6]

Patients with stage IIIb disease with poor performance status are candidates for chest irradiation to palliate pulmonary symptoms (e.g., cough, shortness of breath, or local chest pain). No consistent benefit from any form of immunotherapy has been demonstrated thus far.

T4 or N3, M0

An occasional patient with supraclavicular node involvement who is otherwise a good candidate for irradiation with curative intent will survive 3 years. Although the majority of these patients do not achieve a complete response to radiation therapy, significant palliation often results. Patients with excellent performance status and those who are found to have advanced-stage disease at the time of resection are most likely to benefit from radiation therapy.[7] Adjuvant systemic chemotherapy with radiation therapy has been tested in randomized trials for patients with inoperable or unresectable locoregional NSCLC.[1-3,8] Some patients have shown a modest survival advantage with adjuvant chemotherapy. The addition of chemotherapy to radiation therapy has been reported to improve long-term survival in some,[1,3,4] but not all,[9] prospective clinical studies. A meta-analysis of patient data from 54 randomized clinical trials showed an absolute survival benefit of 4% at 2 years with the addition of cisplatin-based chemotherapy to radiation therapy.[10] The optimal sequencing of modalities remains to be determined and is under study in ongoing clinical trials.[11]

Because of the poor overall results, these patients should be considered for clinical trials; trials examining fractionation schedules, radiosensitizers, radiolabeled antibodies, and combined modality approaches may lead to improvement in the control of regional disease.

Patients with NSCLC can present with superior vena cava syndrome. Refer to the PDQ supportive care summary on superior vena cava syndrome for more information. Regardless of stage, this problem should generally be managed with radiation therapy with or without chemotherapy.

Treatment options:

1. Radiation therapy alone.

2. Chemotherapy combined with radiation therapy.[1-3,8]

3. Chemotherapy and concurrent radiation therapy followed by resection.[12,13]

4. Chemotherapy alone.

1. LeChevalier T, Arriagada R, Quoix E, et al.: Radiotherapy alone versus combined chemotherapy and radiotherapy in nonresectable non-small-cell lung cancer: first analysis of a randomized trial in 353 patients. Journal of the National Cancer Institute 83(6): 417-423, 1991.
2. Morton RF, Jett JR, McGinnis WL, et al.: Thoracic radiation therapy alone compared with combined chemoradiotherapy for locally unresectable non-small cell lung cancer. Annals of Internal Medicine 115(9): 681-686, 1991.
3. Dillman RO, Seagren SL, Propert KJ, et al.: A randomized trial of induction chemotherapy plus high-dose radiation versus radiation alone in stage III non-small-cell lung cancer. New England Journal of Medicine 323(14): 940-945, 1990.
4. Schaake-Koning C, Van dan Bogaert W, Dalesio O, et al.: Effects of concomitant cisplatin and radiotherapy on inoperable non-small-cell lung cancer. New England Journal of Medicine 326(8): 524-530, 1992.
5. Sause WT, Scott C, Taylor S, et al.: Radiation Therapy Oncology Group (RTOG) 88-08 and Eastern Cooperative Oncology Group (ECOG) 4588: preliminary results of a phase III trial in regionally advanced, unresectable non-small-cell lung cancer. Journal of the National Cancer Institute 87(3): 198-205, 1995.
6. Non-small Cell Lung Cancer Collaborative Group: Chemotherapy in non-small cell lung cancer: a meta-analysis using updated data on individual patients from 52 randomised clinical trials. British Medical Journal 311(7010): 899-909, 1995.
7. Komaki R, Cox JD, Hartz AJ, et al.: Characteristics of long-term survivors after treatment for inoperable carcinoma of the lung. American Journal of Clinical Oncology 8(5): 362-370, 1985.
8. Ihde DC: Chemotherapy combined with chest irradiation for locally advanced non-small cell lung cancer. Annals of Internal Medicine 115(9): 737-739, 1991.
9. Blanke C, Ansari R, Mantravadi R, et al.: Phase III trial of thoracic irradiation with or without cisplatin for locally advanced unresectable non-small-cell lung cancer: a Hoosier Oncology Group protocol. Journal of Clinical Oncology 13(6): 1425-1429, 1995.
10. Pignon JP, Stewart LA, Souhami RL, et al.: A meta-analysis using individual patient data from randomised clinical trials (RCTS) of chemotherapy (CT) in non-small cell lung cancer (NSCLC): (2) survival in the locally advanced (LA) setting. Proceedings of the American Society of Clinical Oncology 13: A-1109, 334, 1994.
11. Curran WJ, Radiation Therapy Oncology Group: Phase III Randomized Study of Standard Thoracic Irradiation Following VBL/CDDP vs Standard Thoracic Irradiation and Concurrent VBL/CDDP vs Hyperfractionated Thoracic Irradiation and Concurrent VP-16/CDDP for Locally Advanced, Unresectable, non-Small Cell Lung Cancer (Summary Last Modified 09/98), RTOG-9410, clinical trial, closed, 07/31/1998.
12. Rusch VW, Albain KS, Crowley JJ, et al.: Surgical resection of stage IIIA and stage IIIB non-small-cell lung cancer after concurrent induction chemoradiotherapy: a Southwest Oncology Group trial. Journal of Thoracic and Cardiovascular Surgery 105(1): 97-106, 1993.
13. Albain KS, Rusch VW, Crowley JJ, et al.: Concurrent cisplatin/etoposide plus chest radiotherapy followed by surgery for stages IIIA(N2) and IIIB non-small-cell lung cancer: mature results of Southwest Oncology Group phase II study 8805. Journal of Clinical Oncology 13(8): 1880-1892, 1995.

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