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The Right Setting for “Local Therapy”in Advanced Lung Cancer

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The Right Setting for “Local Therapy” in Advanced Lung Cancer

http://blog.lungevity.org/2012/02/03/th ... ng-cancer/

February 3rd, 2012 - by Dr. Jack West

We hear a lot about advances in ”local therapy” such as focal radiation or surgery that are directed just to a specific focal area, and these refined techniques leads patients and physicians alike wondering how they could be useful for advanced NSCLC. Unfortunately, with rare exceptions, you can’t just cut out or radiate every spot of metastatic disease and realistically treat with curative intent, but that doesn’t mean that local therapies can’t be beneficial for certain settings in advanced NSCLC.

I work very closely with my radiation oncologists, my thoracic surgeons, and my interventional pulmonologist — who all provide local therapies – as part of a unified team for a single patient that provide a range of different treatment options, depending on their case needs. But I do feel that local therapies are all too often misapplied, whether because of financial motivations of the practitioners or the misguided, unclear rationale for doing it (“magical thinking“), which I see as creating a fundamental disconnect between a patient’s expectation and the reality of what such an intervention can deliver. So let’s review where they make good sense, and where they are more of an “if you have a hammer, everything looks like a nail” scenario.

The clearest role for local treatments is to improve QOL and reduce symptoms. Radiation, for instance, is appropriate in metastatic disease in four basic circumstances:

1) brain metastases, which cause symptoms from local growth and swelling, or usually will very soon after detection, if not treated effectively

2) hemoptysis (coughing up blood), where radiation can treat local bleeding from erosion of the cancer into an adjacent blood vessel quite effectively

3) local pain, such as from a bone or soft tissue lesion, in which case radiation-induced shrinkage can improve pain pretty reliably and effectively

4) tumor causing airway compression, in which case radiation-induced response can lead to better air movement

Of course, radiation isn’t the only form of local therapy. Mechanical ones like surgery (to remove a solitary brain metastasis, for instance, or to treat a collapsed vertebra with kyphoplasty) or interventional pulmonology techniques (such as removing tumor from within an airway or placing a stent in an airway compressed from the outside), can also be extremely helpful. Other common local therapies are a pleurodesis (minor surgery to induce scarring outside of the lung that can eliminate a pleural effusion) or placement of a PleuRx catheter (draining pleural fluid outside of the body) to control shortness of breath and the cough that can accompany a recurrent large pleural effusion. These interventions are all extremely appropriate and offer quality of life benefits/symptomatic benefits first and foremost, though they may also improve survival.

The problem that I see with some recommendations for local therapies is that they may be suggested in situations far beyond these settings, such as for asymptomatic and multifocal metastatic disease, where multiply-directed stereotactic radiation is pursued as a presumably curative technique. While there are rare occasions in which treating one or two metastatic lesions with curative intent can be feasible (as I describe in a separate post about when (in my opinion) overlooking the general rules and treating “oligometastatic” lung cancer with curative intent makes sense), focusing on local therapy with curative intent when the cancer isn’t “oligometastic” veers into the realm of magical thinking. Too often, patients and physicians pursue local therapy because they really just want to “treat the scan” as a “just do something” answer, shrinking or removing the cancer by brute force, but if the cancer is active in multiple sites, it can spread and cause new problems before the patient recovers from side effects of local therapy — especially if that’s surgery. And even if the treatment has very little risk, doing a pricey treatment that has no realistic probability of benefit just because it’s possible doesn’t make a lot of sense.

I recognize that such treatments aren’t necessarily being pursued because patients are gunning for them at all costs. Many physicians make futile recommendations and referrals every day, as I see this in the practice patterns all around me. But I believe that very often the true motivation for these doctors is that it is easier for them to sidestep the emotional and time-consuming challenge of discussing the realistic limitations of our more appropriate therapies, especially after a few lines of treatment, than to just glad hand, smile while offering some false hope, and send a patient out of your office for an intervention that is truly just going through the motions. There are also some doctors who just misinformed enough about the biology of metastatic cancer, or just subject to so much wishful thinking on behalf of their patients, that it’s easy to slip into a collective delusion of the benefit a local therapy can provide.

Nobody wants to be the wet blanking saying that certain treatments are a poor option for patients; this is far happy an experience than suggesting a novel,promising idea for patients. So in the end, I think it’s worth not throwing out the baby with the bathwater. We can reiterate that local therapies still have a clear role for many patients with advanced lung cancer. Not only can they be a critical component in maximizing quality of life and minimizing side effects, they may also offer a realistic possibility of an extraordinarily good outcome for well selected patients. They just aren’t broadly helpful when used indiscriminately as a solution for most people with advanced cancer. And we always want to distinguish between offering real hope and false hope to our patients.

I welcome any questions, comments, or objections you’d want to offer.

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