Historically, lung cancer is associated with high mortality rates and little effective therapy. Because this disease predominately affects those of advanced age with significant comorbidities, treatment can be difficult to deliver safely with manageable adverse effects. All of these factors can lead to a sense of futility among clinicians and patients when discussing lung cancer therapy. However, in the last several years novel therapies have emerged to make lung cancer therapy better tolerated and more effective, even among those with significant comorbidities. The introduction of better-tolerated cytotoxic chemotherapy and targeted agents has made lung cancer therapy tenable for many more patients. In addition, the improved response rates seen by matching targeted drugs to specific genetic alterations driving tumor growth have led to improved quality of life and survival among patients with these specific tumors. Thus, although the morbidity and mortality of lung cancer remain high, novel approaches to therapy and improved supportive care have begun to make a significant impact in the burden of this disease.
Chemotherapy, whether an oral targeted drug or an intravenous cytotoxic agent, is used for three main reasons in the treatment of non–small-cell lung cancer (NSCLC): (1) As adjuvant therapy in early-stage disease following potentially curable surgical resection to prevent disease recurrence, (2) as concurrent therapy with radiation in locally advanced disease to radiosensitize the tumor and prevent metastatic disease recurrence, and (3) as palliative therapy in the setting of advanced disease to ease symptoms and prolong survival. This chapter will focus on the role of systemic chemotherapy in the treatment of NSCLC in each of these settings.
Early-Stage Non–Small-Cell Lung Cancer
Surgery remains the standard of care for patients with early-stage disease who do not have medical contraindications. In this setting, surgery provides definitive treatment and allows for more accurate pathologic staging. Staging is central to the therapeutic approach to NSCLC. This entails determination of the extent of invasion of the mediastinal lymph nodes. Mediastinoscopy or fine-needle aspiration (FNA) of lymph nodes by endobronchial ultrasound (EBUS) can be used to sample mediastinal lymph nodes before a surgical resection. As for all surgical interventions for thoracic malignancy, complete nodal sampling or lymph node dissection is an integral part of the procedure. Reliance on noninvasive imaging alone may be inadequate for accurate assessment of the mediastinum (Fig. 114-1).
Computerized tomography (CT) scan of a 59-year-old female with ongoing smoking and chronic cough. The image shows a large nodule in the left lower lobe extending into the pleura. The patient underwent a mediastinal lymph node dissection and left lower lobectomy. She was found to have several hilar lymph nodes involved with tumor at the time of resection, (stage IIA). She received four cycles of cisplatin-based adjuvant chemotherapy following surgical resection.