ESMO Patients Guide
Treatment options for locally advanced (Stage III) NSCLC Treatment for locally advanced disease is likely to involve different types of therapy
Locally advanced NSCLC represents a very diverse disease (see Stages IIIA and IIIB in the AJCC/UICC staging system table) and so it is not possible to recommend a ‘one size fits all’ approach to treatment. Some patients with Stage III NSCLC have a tumour that is considered resectable, i.e. your doctor/surgeon thinks that it can be completely removed by surgery either straight away or after a course of chemotherapy (with or without radiotherapy). On the other hand, some patients with Stage III NSCLC have a tumour that is considered unresectable, i.e. surgery is not possible due to the size/location of the tumour and involvement of lymph nodes in the middle of the chest. The best approach to treatment of Stage III NSCLC is therefore likely to be a combination of various treatment types (surgery, chemotherapy and/or radiotherapy), called multimodal therapy (Postmus et al., 2017; Eberhardt et al., 2015). In patients staged with potentially resectable Stage III NSCLC, treatment options are generally either induction therapy with chemotherapy or chemoradiotherapy, followed by surgery (preferred for those whose tumour is likely to be completely removed by lobectomy) or chemoradiotherapy. In patients with unresectable Stage III NSCLC, the preferred treatment is chemoradiotherapy. Alternatively, sequential chemotherapy and then radiotherapy may be given to patients who are unable to tolerate concurrent treatment (Postmus et al., 2017). Chemotherapy is an integral part of the treatment of Stage III NSCLC. Generally, a cisplatin-based combination regimen (two different drugs) is offered. You will usually be offered 2–4 cycles, whether chemotherapy is given alone or as part of a course of chemoradiotherapy. In some patients who undergo surgery upfront for NSCLC that is thought to be Stage I or II, but found to be Stage III during surgery, then adjuvant chemotherapy will likely be administered after the surgery (Postmus et al., 2017). When radiotherapy is given concurrently with chemotherapy for Stage III NSCLC, it is given as conventional daily doses and treatment should not exceed 7 weeks. It may be given as an accelerated schedule as part of a pre-operative chemoradiotherapy course, but any potential advantages to the likely outcome of surgery will need to be weighed up against potential greater toxicity. When given sequentially, an accelerated schedule of radiotherapy may be given, i.e. higher doses over a shorter timeframe (Postmus et al., 2017). Following first-line treatment, the immunotherapy agent durvalumab may be offered to patients with unresectable disease that has not progressed following platinum-based chemoradiotherapy, if their tumours contain a certain level of PD-L1 (determined by molecular testing using a tumour biopsy) (Imfinzi SPC, 2018).
25
