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Why Add Chemo with Surgery and/or Radiation?


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Why Add Chemo with Surgery and/or Radiation?

November 18th, 2012 - by Dr. Jack West

http://blog.lungevity.org/2012/11/18/wh ... radiation/

The historical standard for early stage non-small cell lung cancer (NSCLC) has been surgery — if it looks like it’s all localized in the chest and you can cut it out, you do that and hope for a cure. So why do we now recommend chemo after surgery, or after radiation for patients with early stage NSCLC who can’t or don’t want to undergo surgery? And why is chemo almost always part of the treatment plan for patients with stage III, locally advanced NSCLC, to be combined with surgery, radiation, or both?

Essentially, the reason is that we’re concerned about both the disease we can see and the disease we can’t see. The reason lung cancer recurs in the liver or skeleton or brain a year or two after the surgeon resects it (so often proudly proclaiming, “I got it all”) is that there is a risk that even after an excellent surgery, there may be microscopic cancer cells circulating in the blood stream, far smaller than any scan or surgeon’s eye can detect. A good surgery or radiation can only work against the cancer in the area that is cut out or radiated, but a systemic therapy like chemotherapy can potentially kill off any stray cancer cells that are beyond the range of the surgeon or radiation oncologist. The risk of microscopic cancer cells is related to things like the size of the primary tumor and the extent of spread to lymph nodes, which is why these are factors that are important in staging and the recommendation for or against post-operative chemotherapy.

One other factor that is important in the setting of locally advanced NSCLC, where radiation therapy is typically a component of the treatment recommendation, is that chemotherapy can serve as a radiosensitizer, potentiating the anti-cancer effect of the radiation. So chemotherapy in this setting can help against both the cancer that is visible and the potential of microscopic cancer cells outside of the radiation field.

Because the risk of systemic spread is too high to ignore in all but the earliest stage cancers, chemo tends to be either the cornerstone of treatment, such as in the setting of advanced lung cancer, or a supportive component to supplement the primary role of the local therapy — whether surgery, radiation, or both — that are treating the visible disease in the chest.

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