Treatment According to Stages

Questions to Ask Your Doctor About Lung Cancer
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Treatment According to Stages

Stage 1 and Stage 2
Surgical resection of the tumor is the principle form of treatment for patients with Stage 1 or Stage 2 lung cancer. If, during surgery, the resected lung margins are found to be close to or involved with the tumor, the physician may recommend additional treatment in the form of radiotherapy (radiation therapy). Radiotherapy is given to reduce the rate of tumor re-growth in the area of the original tumor.

If a patient is not medically able to withstand tumor resection, radiotherapy alone may be administered to destroy the tumor tissue.

Stage 3
Experts often divide Stage 3 cancer patients into three groups: patients with obvious Stage 3 disease who show abnormal, enlarged lymph nodes on chest x-ray or CT scan; patients with normal-appearing, but cancerous mediastinal lymph nodes that are identified during mediastinoscopy (examination of the chest cavity with an endoscope); and classic Stage 3b patients with tumors of any size and cancerous lymph nodes within the mediastinum and/or the carina (tracheal ridge), hilum ("pit" for entry/exit of vessels within the lungs), upper ribs, or upper collarbone region.

The first group of patients—those with abnormal, enlarged lymph nodes—have a high probability of cancer in those nodes. These patients are not considered primary surgical candidates, but they may benefit from a combination treatment plan involving both radiation and chemotherapy. Research suggests that concurrent treatment produces better response rates than sequential (one at a time) treatment; however, patients report more side effects with combined, concurrent radiotherapy and chemotherapy. It is unclear whether or not disease-free or overall survival is improved when surgery is performed after concurrent combination therapy.

The second group of patients—those with normal-appearing mediastinal nodes—may undergo surgery for tumor resection. In many of these patients patients, histopathologic examination reveals that the lymph nodes are actually cancerous. Another treatment option is to have preoperative chemotherapy or chemo-radiotherapy and, if a response is seen, to undergo follow-up resection of any remaining tumor. Preoperative therapy should be given if available. Clinical trials may provide helpful forms or therapy for these patients, so the availability of research protocols should be discussed.

The third group of patients—those with Stage 3b cancer—are not surgical candidates. A combination treatment plan with chemo-radiotherapy should be considered for those who have noncancerous effusion (fluid that is free of cancer cells). Both patient and doctor should decide on the timing of therapy—concurrent or sequential. Patients who have cancerous effusion should consider the benefits of chemotherapy alone compared to no therapy with comfort care. Unfortunately, patients with cancerous effusions often tend to survive only as long as Stage 4 patients (roughly 8 months), despite aggressive therapy.

Stage 4 or Recurrent Lung Cancer
Patients who have Stage 4 or recurrent lung cancer have the options of chemotherapy alone versus no therapy with comfort care. Clinical findings indicate that treatment for Stage 4 patients can improve overall survival when compared with comfort care only. In addition, chemotherapy may help to relieve symptoms in patients who experience significant symptoms from their disease.

Several chemotherapeutic agents are available to patients with Stage 4 disease. These agents include paclitaxel (Taxol®) and carboplatin (Paraplatin®), as well as newer agents such as vinorelbine tartrate (Navelbine®), gemcitabine hydrochloride (Gemzar®), docetaxel (Taxotere®), and combinations of the above with cisplatin (Platinol®).

Limited-Stage Small Cell Lung Cancer (SCLC)
The treatment of limited-stage SCLC is very physically demanding. Therefore, the oncology team evaluates each patient's ability to tolerate whole-body therapy (e.g., chemotherapy) and loco-regional therapy with radiation or surgery. If a lung cancer patient is unable to walk at least 50% of the time, and if he or she does not have good function of the liver, kidney, and cardiopulmonary (heart/lung) system, it is unlikely that aggressive treatment can be tolerated. (The death rate from aggressive combinations of chemo-radiotherapy can be as high as 5–8%.)

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Patients who have localized disease and are in relatively good health may be good candidates for aggressive combination therapy. Combination therapy may consist of one of several treatment options, including the following:

• Surgery followed by adjuvant (additional, assisting) chemotherapy when no obvious cancer is present
• Chemotherapy followed by radiotherapy (sequential therapy)
• Chemotherapy plus radiotherapy (concurrent therapy)
• Chemotherapy alternating with radiotherapy

Although most experts agree that chemo-radiotherapy is preferred over one therapy alone, many issues—such as the sequencing and timing of therapy—remain unanswered. Participation in a clinical trial is highly recommended if one is available.

Cranial (head) radiation therapy (PCI) is another option for patients with limited-stage disease. Some experts believe that prophylactic, or disease-preventing, cranial radiation is helpful, whereas others maintain that a "watch and wait" approach is more practical. Studies have not shown significant improvements in survival. Cranial radiation can decrease the risk of developing brain metastases in SCLC patients; however, the need for cranial radiation is a determination that is best made by the patient and his or her physician.

Extensive-Stage Small Cell Lung Cancer (SCLC)
If patient with extensive-stage disease is not medically stable or has poor health, only comfort care should be considered. For all other extensive-stage SCLC patients, chemotherapy is a suitable treatment strategy, since it can prolong survival. However, the choice of chemotherapy should take into account a number of factors, such as the overall benefit of therapy (lengthened survival), the physical toll of therapy (side effects, need for frequent physician visits), and the ultimate effects or achievements of therapy (e.g., both short- and long-term goals).

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