Episode 026: Lung Cancer Series, Pt. 4: Treatment of early stage NSCLC

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 Please visit our website (TheFellowOnCall.com) for more information Twitter: @TheFellowOnCall Instagram: @TheFellowOnCall Listen in on: Apple Podcast, Spotify, and Google Podcast