Multimodality therapy in unresected stage III non-small cell lung cancer: the American Cooperative Groups' Experience

Role of chemotherapy in stages I to III non-small cell lung cancer

The management of resectable non-small cell lung cancer (NSCLC) has been the focus of extensive investigation over the last decade. Nonetheless, existing management strategies are suboptimal for all stage groupings. The only exception is complete resection for stage IA NSCLC, in which a cure is achieved in 70 to 85% of patients. A number of studies demonstrate that adjuvant chemotherapy may be associated with some biological effect. Nonetheless, chemotherapy remains experimental and cannot be definitively recommended outside the context of a randomized trial. Radiation therapy appears to be associated with a reduction in local recurrence in stage II NSCLC. With regard to potentially resectable stage IIIA NSCLC, the results of randomized trials support the conclusion that induction chemotherapy followed by resection (with or without postoperative radiation) may enhance survival compared to that achieved with resection alone. Among patients with stage IIIA and IIIB NSCLC who are treated without resection, numerous phase III studies demonstrate that induction chemotherapy with definitive radiation improves outcome when compared to thoracic radiation therapy alone. While there may be an advantage for concurrent chemoradiation compared to sequential therapy, definitive results are not yet available to support this conclusion. While the magnitude of benefit associated with induction chemotherapy or chemoradiation in regionally advanced NSCLC is debatable, the results of multimodality studies provide a basis for optimism that real therapeutic progress is being achieved. Further study of therapeutic strategies that incorporate aggressive systemic treatment and local-regional therapy in stage IIIA and IIIB NSCLC is warranted. Moreover, completion of randomized studies focusing on the role of adjuvant chemotherapy in stage IB and stage II NSCLC should be given priority.

Non-surgical therapy for patients with advanced non-small cell lung cancer

Advanced non-small cell lung cancer (NSCLC) denotes those of TNM stage III and IV. NSCLC has its specific characteristics in respect of oncological behaviour, molecular biology, sensitivity to chemotherapy (CT) and radiotherapy (RT), and requires different therapeutic strategies in comparison with small cell lung cancer. The therapies include: (1) surgery in combination with new effective drugs is resulted in improved RR from 15% a decade ago to 40-60% today. Cisplatin (C-DDP) is the most attractive drug in the treatment of NSCLC, in lengthening the life-span of Stage IV NSCLC patients and as an indispensable sensitizer in RT. Taxinol, Gemcitabine (GEM), Navelbine (NVB), Edatrexate (ETX), CPT-11 and high dose Epirubicin (EPI HD) are recommended as new effective drugs. Response rates recently reported for the combination CT with the drugs mentioned above for NSCLC are from 30-65%, and with 8-42 weeks of MST. Induction or neoadjuvant therapies for advanced NSCLC, with 40-69% of RR, 25-29% of complete resection rate, 8-34% of CR and 17-45% of one year SR are reviewed. Eight random studies comparing MST between CT with C-DDP and best supportive care for NSCLC are statistically significant. (2) RT for Stage III NSCLC with 2 year and 5 year survivals of 20 and 5% respectively. Although such outcome is hardly acceptable, RT sensitizer, modified RT techniques and chemoradiotherapy (CRT) are imperative to improve the effect of RT in advanced NSCLC. Clinical literature suggest that CRT is better than RT, though without marked difference. Further studies and sufficient follow-up are necessary to judge the efficacy in terms of long-term survival and toxic reaction. (3) Biological therapy: gene therapy of NSCLC is still in the experimental and developmental stage. Of biological response modifier (BRM), alpha IFN in 11 cases of NSCLC with RR of 9% and MST of 14 months, IL-2 and LAK cell treatment in 11 cases with RR of 9% and MST of 18 months are reported. Instillation of BRM such as IL-2 or alpha-IFN into the pleura after drainage of cancerous effusion has been reported as the most effective for those whose RR is of 80-90% and the clinical response time is fairly long. Hematological cytokine as a protective adjuvant therapy against CT/RT toxicity makes high dose of CT possible and raises the response and patient tolerance. In multimodality therapy, it plays an important role to reduce post CT infection and septicemia.