Although lung cancer remains the leading cause of cancer death in the United States, a reduction in smoking rates and recent medical advances have improved the overall mortality rate. The decline in lung cancer mortality rates has accelerated from a 3% decrease (2008–2013) to 5% (2013–2017).1 Noted medical advances driving the decrease include lung cancer screening and stereotactic body radiotherapy. However, improved systemic therapy with immune checkpoint inhibitors and targeted agents also have had an impact. These improvements have led to prolonged survival in those with metastatic disease. Treatment with targeted agents or immunotherapy has led to a significant percentage of these patients surviving 5 years or more.2–4 These novel therapies have emerged to make lung cancer therapy better tolerated and more effective, even among those with significant comorbidities. Thus, although the morbidity and mortality of lung cancer remain high, novel approaches to therapy have begun to make a substantial impact.
Chemotherapy is used for three main reasons in the treatment of non–small-cell lung cancer (NSCLC): (1) as adjuvant therapy in early-stage disease, either preceding or following potentially curable, surgical resection to prevent disease recurrence; (2) as concurrent therapy with radiation in locally advanced disease to radiosensitize the tumor for improved local response and prevent metastatic disease recurrence; and (3) as palliative therapy in the setting of advanced disease to ease symptoms and prolong survival. Immunotherapy has emerged as an important addition to conventional chemotherapy for treatment of advanced disease. This chapter focuses on the role of systemic chemotherapy and immunotherapy in the treatment of NSCLC in each of these settings.
ADJUVANT THERAPY FOR 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 and 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 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 an accurate assessment of the mediastinum (Fig. 114-1).
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.