Episode Details

Lung cancer is one of the most commonly diagnosed type of cancer and so it is fitting that we start the first of our disease-specific oncology series with this diagnosis. This week, we round out our discussion of early stage lung cancer treatment!

* When deciding if a patient can get surgery upfront or not, remember the three “Fellow on Call” criteria for early stage lung cancer:  

- Mass invading other structures or mediastinum

- Central lymph nodes (single digit)

- Tumor >7 cm

* If surgery is NOT an option at this time, where do we go from here?

- Treat with upfront concurrent definitive chemoradiation

- Treat with “induction” chemotherapy or induction concurrent chemoradiation

**If surgery is/may be possible**

*What are the goals of “induction” treatments? 

- Eradicate microscopic disease

- Improved local control, possibly shrinkage

- Adding radiation may allow you to downstage tumor or lymph nodes to have a possible improvement in surgical outcomes

* What sorts of discussions are being had a thoracic tumor board in patients with newly diagnosed early stage NSCLC? 

- Is the patient a surgical candidate?

- If the patient is not a surgical candidate, then what are the options:

--Definitive concurrent chemoradiation (usually) followed by immunotherapy

---Pearl 1: Always choose this if surgeon thinks the patient is unresectable in general even with an induction approach

---Pearl 2: Always choose this if 2 out of 3 criteria we discussed above are met

---Pearl 3: Always choose this if N3 disease

- “Induction” regimen with either chemotherapy alone or concurrent chemoradiation followed by surgery

* What’s the idea behind “induction” chemo or chemoradiation? 

- There is a chance that patients with these high risk features may already have micrometastatic disease, so treatment upfront can help address that

- There is a chance that after surgery, patient may suffer deconditioning, which may preclude the use of chemo +/- radiation (up to 90% of patients are often eligible for chemoradiation before surgery; this drops to ~60% after surgery)

- Local disease control to achieve the best possible surgical outcome (R0 resection) and also prevent any microscopic residual disease from then having the opportunity to spread systemically, especially in areas where the mass may be adjacent to many blood vessels or lymph nodes

* What to treat with in the neoadjuvant setting?

- Platinum containing regimens (“platinum doublets”):

-- Carboplatin + paclitaxel

-- Cisplatin + etoposide

-- Cisplatin + gemcitable

-- Cistplain + pemetrexed

- Can