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 diseaseApproach 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 radiationSpeaking 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**PneumonectomyWhat 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: @TheFellowOnCallInstagram: @TheFellowOnCallListen in on: Apple Podcast, Spotify, and Google Podcast