Stage IIIB lung cancer – pro

Chemoradiation is standard of care for stage IIIB and some IIIA non-small cell lung cancer. Stage III disease subsummizes a rather heterogeneous patient group concerning the overall prognosis including patients with more loco-regional risks (e.g. ‘T4’) or either distant risks (‘N2/N3’ or ‘large tumour burden’). Any comprehensive judgement of treatment strategies has to acknowledge this marked heterogeneity. 

Patients with proven stage III disease represent a rather heterogeneous patient population concerning co-morbidity risks including pulmonary function limitations, cardio-vascular or cerebro-vascular co-morbidities, or other major co-morbidities with evident organ dysfunctions. There may be subsets of patients that may profit from definitive surgery, but these subsets have not yet been clearly defined. Chemoradiation is standard. There is some evidence, however,  that selected T4N0–1 patients should be taken to definitive thoracotomy. Other patients groups, including those with important co-morbidities, may have the best chance of cure and long-term survival with bi-modality protocols of concurrent chemoradiotherapy and this is the most common approach. NCCN recommends chemoradiotherapy and the recommended regimens include etoposide/cisplatin, navelbine/ cisplatin and cisplatin with gemcitabine or docetaxel. Carboplatin is sometimes used in lieu of cisplatin and there is sufficient evidence from randomized studies that complare the two, to show that these two drugs are essentially equivalent.

In patients with Stage III non-small-cell lung cancer, a randomized study showed that induction chemotherapy with cisplatin and vinblastine before radiation significantly improves median survival (by about four months) and doubles the number of long-term survivors, as compared with radiation therapy alone. NCCN list sequential chemo – chemo/RT with paclitaxel carbo as a recommended option.

Turrisi AT III, Kim K, Blum R et al. Twice-daily compared with once-daily thoracic radiotherapy in limited small-cell lung cancer treated concurrently with cisplatin and etoposide. N Engl J Med 1999; 340: 265–271.[

Clamon G, Herndon J, Cooper R et al. Radiosensitization with carboplatin for patients with unresectable stage III non-small-cell lung cancer: a phase III trial of the Cancer and Leukemia Group B and the Eastern Cooperative Oncology Group. J Clin Oncol 1999; 17: 4–11

A. W. Blackstock and R. Govindan
Definitive Chemoradiation for the Treatment of Locally Advanced Non Small-Cell Lung Cancer
J. Clin. Oncol., September 10, 2007; 25(26): 4146 – 4152.

A. Auperin, C. Le Pechoux, J. P. Pignon, C. Koning, B. Jeremic, G. Clamon, L. Einhorn, D. Ball, M. G. Trovo, H. J. M. Groen, et al.
Concomitant radio-chemotherapy based on platin compounds in patients with locally advanced non-small cell lung cancer (NSCLC): A meta-analysis of individual data from 1764 patients
Ann. Onc., March 1, 2006; 17(3): 473 – 483.

Dillman, RO, Seagren, SL, Propert, KJ, Guerra, J, Eaton, WL, Perry, MC, Carey, RW, Frei, EF, Green, MR
A randomized trial of induction chemotherapy plus high-dose radiation versus radiation alone in stage III non-small-cell lung cancer
N Engl J Med 1990 323: 940-945

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