Diagnosing and Treating Adult Cancers and Associated Impairments (2021) / Chapter Skim
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6 Lung Cancer
6 Lung Cancer
Pages 155-192
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To help manage these impairments and functional limitations as well as the adverse effects from both the cancer and its treatment, palliative and supportive care may be recommended for patients at the time of their diagnosis or during the course of treatment. Two of the most common comorbidities in lung cancer survivors are chronic obstructive pulmonary disease (COPD)
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, so the development of a screening test for high-risk individuals is an important advancement in lung cancer care (de Koning et al., 2020; National Lung Screening Trial Research Team et al., 2011)
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When it is suspected, protocols for diagnosis and cancer staging, which often occur simultaneously, are the foundations for clinical decisions about appropriate lung cancer treatment. DIAGNOSIS AND STAGING OF LUNG CANCER Diagnosing lung cancer, classifying the type, and determining the extent of the disease (cancer stage)
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may be needed to confirm lung cancer subtypes or to distinguish metastatic cancers that may mimic primary lung cancer. In addition, there are molecular and immunologic techniques for more complete pathological profiling of NSCLC that not only aid lung cancer diagnosis but that are essential for treatment decisions and prognosis.
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The N stage characterizes the location of lymph node involvement within the chest as follows: N0 indicates no nodal spread; N1 indicates cancer involved nodes limited within the lung proper that could TABLE 6-1 Anatomic Staging of Lung Cancer Stage Detailed Stage TMN Stage 0 Stage 0 • Tis, N0, M0 I Stage IA • T1mi, N0, M0 • T1, N0, M0 Stage IB • T2, N0, M0 II Stage IIA • T2, N0, M0 Stage IIB • T1, N1, M0 • T2, N1, M0 • T3, N0, M0 III Stage IIIA • T1, N2, M0 • T2, N2, M0 • T3, N1, M0 • T4, N0, M0 • T4, N1, M0 Stage IIIB • T1, N3, M0 • T2, N3, M0 • T3, N2, M0 • T4, N2, M0 Stage IIIC • T3, N3, M0 • T4, N3, M0 IV Stage IVA • Any T, any N, M1 Stage IVB • Any T, any N, M1 NOTE: M = presence or absence of distant metastasis; N = extent of regional lymph node spread; T = size or extent of the primary tumor; Tis = carcinoma in situ; T1mi = minimally invasive adenocarcinoma. SOURCES: Used with the permission of the American College of Surgeons, Chicago, Illinois.
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. Stage III is defined by larger cancers and those that have spread to the mediastinum or low neck lymph node regions outside of the lung (N2 or N3 regions)
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Lung cancer treatments are generally categorized as local/regional therapies (surgery, radiation therapy, ablation) or systemic therapies (chemotherapy, immunotherapy, targeted therapy)
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. Treatment of Non-Small-Cell Lung Cancer This section describes the standard therapies that are used to treat NSCLC and is organized into treatments for cancer stages I–II, stage III, and stage IV.
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are, by definition, upstaged to stage III. Radiation therapy When surgical resection of a NSCLC stage I or nodenegative stage II tumor is not feasible, radiation as a single treatment modality is often used.
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, are discussed in the section on Life After Lung Cancer Diagnosis. Percutaneous image-guided ablation approaches Although radiation therapy is the preferred treatment approach for patients with stages I–II NSCLC when surgery is not an option, in some cases (e.g., small tumors in stage I NSCLC)
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. Stage III NSCLC Stage III NSCLC represents a heterogeneous group of diseases divided into three major categories (see Table 6-1)
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is the standard-of-care treatment for unresectable stage III NSCLC and may also be administered prior to, or following, surgical resection in patients for whom surgery may be curative. More than 40 years ago patients with unresectable stage III NSCLC were treated with radiation therapy alone (60 Gy in 30 treatments)
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. Acute toxicities of chemoradiation For most patients with stage III NSCLC, a common side effect of concurrent chemoradiation, in addition to fatigue and skin irritation, is radiation esophagitis resulting from radiation targeting lymph nodes located in close proximity to the esophagus.
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Radiation pneumonitis is considered a subacute reaction because it generally does not develop in the acute setting (during chemoradiation therapy) and it does not develop in the late setting (>6 months after the end of radiation)
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Currently, FDA-approved inhibitors for EGFR, ALK, ROS, BRAF, MET and RET are included in national guidelines and are standard of care for NSCLC (ACS, 2020; Bironzo and Di Maio, 2018; PDQ® Adult Treatment Editorial Board, 2020)
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. Data from prospective randomized clinical trials of oligometastatic NSCLC support aggressive local regional therapy and ablation of metastases (Gomez et al., 2016, 2019; Iyengar et al., 2018; Palma et al., 2019)
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for each case. Treatment of Small-Cell Lung Cancer Unlike other common solid tumors, SCLC is very sensitive to chemotherapy and radiation therapy when it is initially diagnosed.
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. However, this approach is currently being questioned because of late cognitive effects of prophylactic cranial irradiation and because of the option of effective MRI surveillance and stereotactic radiation therapy, which can effectively manage brain metastases after they are diagnosed (Lukas et al., 2017)
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scan; endobronchial • Surgery ± radiation ± neoadjuvant ultrasound; mediastinoscopy; chemotherapy percutaneous lung biopsy Unresectable tumors: • Chemotherapy + radiation + immunotherapy Stage IV CT scan; PET scan; MRI • Chemotherapy ± immunotherapy ± (metastatic) scan; needle biopsy; targeted therapy molecular and DNA • Radiation for palliation biomarkers Small-cell lung cancer Limited stage CT scan; MRI scan; bone • Chemotherapy with radiation ± scintigraphy; FDG-PET scan prophylactic cranial irradiation Extensive stage CT scan; MRI scan; bone • Chemotherapy ± immunotherapy ± scintigraphy; FDG-PET scan radiation NOTES: The symbol ± in the treatment column means "with or without." The exact treatment regimen is determined on a case-by-case basis.
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. Between 80% and 100% of all cancer survivors experience pain (Rausch et al., 2012)
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. Psychological distress in long-term cancer survivors has been associated with non-adherence to cancer surveillance screening recommendations (Katz et al., 2009)
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. After surgical resection of NSCLC, QOL indicators for physical functioning, pain, and dyspnea are significantly impaired even at 24 months.
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This prophylactic cranial irradiation is associated with cognitive impairment; an oral medication, memantine, has been shown to modestly improve neurocognitive function in patients receiving whole brain radiation therapy (Brown et al., 2013)
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. Currently, there is an ongoing randomized clinical trial of hippocampal avoidance prophylactic cranial irradiation versus standard prophylactic cranial irradiation for patients with SCLC (The Netherlands Cancer Institute and Dutch Cancer Society, 2013)
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Conclusions 1. Reductions in smoking and improvements in screening, diagnosis, and treatment options have contributed to lower lung cancer death rates; however, survivors experience numerous adverse effects and impairments that can result in functional limitations.
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2009. Radiotherapy plus chemotherapy with or without surgical resection for stage III non-small-cell lung cancer: A phase III randomised controlled trial.
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2020. Long-term results of NRG oncology RTOG 0617: Standard- versus high-dose chemoradiotherapy with or without cetuximab for unresectable stage III non small-cell lung cancer.
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2018. Treatment of locally advanced, unresectable or medically inoperable stage III non-small-cell lung cancer; the past, present and future of chemora diotherapy.
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2006. Radiofrequency ablation followed by conventional radiotherapy for medically inoperable stage I non-small cell lung cancer.
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2003. Effect of number of lymph nodes sampled on outcome in patients with stage I non-small-cell lung cancer.
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maintenance therapy or observation for patients with oligometastatic non-small-cell lung cancer: Long-term results of a multi-institutional, phase II, randomized study. Journal of Clinical Oncology 37(18)
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2008. Phase III trial of maintenance gefitinib or placebo after concurrent chemoradiotherapy and docetaxel consolidation in inoperable stage III non-small-cell lung cancer: SWOG S0023.
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2020a. NCCN clinical practice guidelines in oncology: Small cell lung cancer.
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2020. PDQ non-small cell lung cancer treatment.
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2018. Stereotactic body radiotherapy for early-stage non-small-cell lung cancer: American So ciety of Clinical Oncology endorsement of the American Society for Radiation Oncology evidence-based guideline.
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2015. Use of thoracic radiotherapy for exten sive stage small-cell lung cancer: A phase 3 randomised controlled trial.
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2009. Systematic review and meta analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer.
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