A stage IIIB non-small cell lung cancer (NSCLC) involves lymph nodes on the opposite side of the chest or above the collar bone, or is extensive (involves organs such as the heart or trachea) and also involves lymph nodes in the center of the chest (mediastinum) or near where the windpipe divides.
A variety of factors ultimately influence a patient’s decision to receive treatment of cancer. The purpose of receiving cancer treatment may be to improve symptoms through local control of the cancer, increase a patient’s chance of cure, or prolong a patient’s survival. The potential benefits of receiving cancer treatment must be carefully balanced with the potential risks of receiving cancer treatment.
The following is a general overview of the treatment of stage IIIB non-small cell lung cancer. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied. The information on this Web site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.
Most new treatments are developed in clinical trials. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Participation in a clinical trial may offer access to better treatments and advance the existing knowledge about treatment of this cancer. Clinical trials are available for most stages of cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. To ensure that you are receiving the optimal treatment of your cancer, it is important to stay informed and follow the cancer news in order to learn about new treatments and the results of clinical trials.
Optimal treatment of patients with stage IIIB lung cancer often requires more than one therapeutic approach. Thus, it may be important for patients to be treated at a medical center that can offer multi-modality treatment involving medical oncologists, radiation oncologists, surgeons and specialists in pulmonary medicine.
Stage IIIB NSCLC often cannot be effectively removed with surgery. Historically, most patients with stage IIIB cancers were treated with radiation or with chemotherapy and less than 10% of patients survived 5 years with either treatment approach. Doctors have more recently learned that combining chemotherapy with radiation therapy may improve a patient’s survival. The results of a clinical trial comparing sequential chemotherapy and radiation therapy to radiation therapy alone was reported in the early 1990s and demonstrated that patients treated with the sequential approach were almost three times more likely to be alive 5 years from treatment when compared to patients treated with radiation alone. More recently, clinical studies suggest that the concurrent use of chemotherapy and radiation therapy also improves survival compared to radiation alone. These and other clinical trials have established combined modality therapy utilizing both chemotherapy and radiation therapy as a standard treatment approach for patients with stage IIIB cancers.
Patients with stage IIIB NSCLC who are unable or unwilling to receive radiation therapy can be treated with chemotherapy alone to alleviate the symptoms of their disease and prolong survival time. Over the past several years, chemotherapy has commonly consisted of a two-drug combination containing a platinum-containing compound (Platinol® or Paraplatin®), combined with a second chemotherapy agent.
A targeted therapy is one that is designed to treat only the cancer cells and minimize damage to normal, healthy cells. Cancer treatments that “target” cancer cells may offer the advantage of reduced treatment-related side effects and improved outcomes.
Avastin® (bevacizumab): Avastin is a type of targeted therapy that slows or stops the growth of blood vessels that deliver blood to the cancer, effectively starving the cancer of the oxygen and nutrients it requires to survive and grow. Avastin, in combination with the chemotherapy drugs paclitaxel and carboplatin, is FDA-approved for the treatment of advanced, non-squamous non-small cell lung cancer.
Xalkori™ (crizotinib): Up to 7% of non-small cell lung cancers have an abnormal version of the ALK gene that contributes to the growth and development of cancer cells. Xalkori is an oral medication that blocks certain proteins, including the protein produced by this abnormal gene. For advanced non-small cell lung cancers that test positive for the ALK gene mutation, Xalkori has produced very promising rates of response.1
Maintenance therapy refers to treatment that is given after initial treatment but before cancer progression. It is a relatively new approach to lung cancer treatment. Drugs that have been approved for maintenance therapy in selected patients include Alimta® (pemetrexed) and Tarceva® (erlotinib). For patients who are candidates for maintenance therapy, the approach has been shown to delay cancer progression and improve overall survival.2 3
Many NSCLC cases occur in people over the age of 70, but there is limited information about how best to treat older patients. As a result of the limited information and concern that elderly patients will not be able to tolerate aggressive treatment, older patients may be treated with single-agent chemotherapy rather than the combination chemotherapy that is commonly used in younger patients. Studies have suggested, however, that although combination chemotherapy increases side effects, it also improves survival among elderly patients.4 Because relatively few studies have focused on older lung cancer patients, additional research on this issue is warranted.
While some progress has been made in the treatment of stage IIIB NSCLC, the majority of patients still experience disease recurrence and better treatment strategies are needed. The progress that has been made in the treatment of NSCLC has resulted from improved pre-treatment staging of the cancer, development of multi-modality treatments and participation in clinical trials. Future progress in the treatment of NSCLC will result from continued participation in appropriate clinical trials. Currently, there are several areas of active exploration aimed at improving the treatment of stage IIIB NSCLC.
New Approaches to Targeted Therapy: Researchers are continuing to evaluate new targeted therapies for the treatment of NSCLC. Tarceva, for example, which already plays a role in lung cancer maintenance therapy and second- and third-line lung cancer treatment, also appears to improve outcomes among newly diagnosed patients. Patient selection is important, however: studies in newly diagnosed patients suggest that the benefit of Tarceva is largely restricted to patients whose cancer has a mutation in the EGFR gene.5 Erbitux® (cetuximab) is another targeted therapy that has produced promising results in selected patients with NSCLC.6
Improved Approaches to Radiation Therapy: New radiation therapy technology is allowing physicians to more precisely target the cancer. This allows higher doses of radiation to be delivered to the cancer while reducing damage to normal tissue. For example, by using a special computer and CT scan, radiation therapy can be delivered more precisely to the cancer in the lungs. This technique is called 3-dimensional conformal radiation therapy.
2 Ciuleanu T, Brodowicz T, Zielinski C et al. Maintenance pemetrexed plus best supportive care versus placebo plus best supportive care for non-small-cell lung cancer: a randomised, double-blind, phase 3 study. Lancet. 2009;374:1432-40
3 Cappuzzo F, Ciuleanu T, Stelmakh L et al. Erlotinib as maintenance treatment in advanced non-small-cell lung cancer: a multicentre, randomised, placebo-controlled phase 3 study. Lancet Oncology. 2010;11:521-529.
4 Quoix E, Zalcman G, Oster J-P et al. Carboplatin and weekly paclitaxel doublet chemotherapy compared with monotherapy in elderly patients with advanced non-small-cell lung cancer: IFCT-0501 randomised, phase 3 trial. The Lancet. Early online publication August 9, 2011.
5 Zhou C, Wu Y-L, Chen G et al. Erlotinib versus chemotherapy as first-line treatment for patients with advanced EGFR mutation-positive non-small-cell lung cancer (OPTIMAL, CTONG-0802): A multicentre, open-label, randomized, phase 3 study. Lancet Oncology. Early online publication July 22, 2011.