Treatment of Stage I and II Non-small Cell Lung Cancer

Abstract

Objectives: Stage III non-small cell lung cancer (NSCLC) describes a heterogeneous population with disease presentation ranging from apparently resectable tumors with occult microscopic nodal metastases to unresectable, bulky nodal disease. This review updates the published clinical trials since the last American College of Chest Physicians guidelines to make treatment recom-mendations for this controversial subset of patients. Methods: Systematic searches were conducted through MEDLINE, Embase, and the Cochrane Database for Systematic Review up to December 2011, focusing primarily on randomized trials, selected meta-analyses, practice guidelines, and reviews. Results: For individuals with stage IIIA or IIIB disease, good performance scores, and minimal weight loss, treatment with combined chemoradiotherapy results in better survival than radio-therapy alone. Consolidation chemotherapy or targeted therapy following defi nitive chemoradia-tion for stage IIIA is not supported. Neoadjuvant therapy followed by surgery is neither clearly better nor clearly worse than defi nitive chemoradiation. Most of the arguments made regarding patient selection for neoadjuvant therapy and surgical resection provide evidence for better prognosis but not for a benefi cial impact of this treatment strategy; however, weak comparative data suggest a possible role if only lobectomy is needed in a center with a low perioperative mor-tality rate. The evidence supports routine platinum-based adjuvant chemotherapy following com-plete resection of stage IIIA lung cancer encountered unexpectedly at surgery. Postoperative radiotherapy improves local control without improving survival. Conclusions: Multimodality therapy is preferable in most subsets of patients with stage III lung cancer. Variability in the patients included in randomized trials limits the ability to combine results across studies and thus limits the strength of recommendations in many scenarios. Future trials are needed to investigate the roles of individualized chemotherapy, surgery in particular cohorts or settings, prophylactic cranial radiation, and adaptive radiation. CHEST 2013; 143(5)(Suppl):e314S–e340S Abbreviations: ACCP 5 American College of Chest Physicians; EORTC 5 European Organisation for Research and Treatment of Cancer; HR 5 hazard ratio; IASLC 5 International Association for the Study of Lung Cancer; IMRT 5 inten-sity-modulated radiotherapy; MLND 5 mediastinal lymph node dissection; NSCLC 5 non-small cell lung cancer; PCI 5 prophylactic cranial irradiation; PORT 5 postoperative radiotherapy; RCT 5 randomized controlled trial;