My father is 86 and has an early stage NSCLC...

[CindyA]

My father is 86 and has an early stage NSCLC: What are his treatment options?

October 27th, 2013 - by Dr. Jack West

The current standard of care for treating early stage NSCLC is surgery, but not everyone is a strong candidate for surgery. A patient I just recently saw in clinic illustrates the challenge we face when patients who are elderly and/or sick for various reasons present with a curable lung cancer. This particularly gentleman is 86, actually never smoked cigarettes but “ate smoke” as a fireman with no protective mask for decades and now has COPD, and also significant heart disease, with a prior heart attack nearly 30 years ago and several other heart problems since then. He was involved in a motor vehicle accident a month ago (which he hastens to note wasn’t his fault) which led to his getting imaging of his neck that incidentally revealed a 2.5 cm mass in the apex (top) of his left lung, no enlarged lymph nodes. He had no symptoms from it yet.

This is, in fact, how most early stage lung cancers are found: rather than being related to symptoms, they are found incidentally when someone undergoes pre-operative imaging for heart disease, gall bladder surgery, etc., or now increasingly for lung cancer screening.

So what do we do when someone is a marginal or poor candidate for a standard lung cancer surgery but has a potentially curable lung cancer? Historically, the “gold standard” is a surgery that removes an entire lung lobe (1/3 of the right lobe or 1/2 of the left lung, which is a little smaller because the heart sits in the left side of the chest). And until a few years ago, lung cancer surgery almost always involved a long incision and cutting through several ribs. Many patients were old enough and/or frail enough that surgery may have been prohibitively dangerous.

Thankfully, our discussions now may include a few options in such patients. Many lung cancer surgeons now routinely offer a minimally invasive video-assisted thoracoscopic surgery (VATS), which allows many patients to have surgery through a few dime-sized “ports”. This helps remarkably with the rigors of surgery. In addition, there is some evidence that patients with resectable lung cancer who are 75 or older do just as well in terms of survival with a wedge resection – which removes just the tumor with a margin of normal lung around it — rather than a full lobectomy.

But the biggest development for such patients is the advent of stereotactic body radiation therapy (SBRT). Radiation therapy was always an option for “medically inoperable” early stage lung cancer, but that typically required a patient to come in for treatment every day for 6-7 weeks. Instead, the new procedure of SBRT, which is available at more and more centers, is a very appealing alternative for patients to undergo a treatment that gives high doses of radiation in just a few treatments — typically just 4 or 5 over a week and a half. Most exciting is the growing evidence that people with no nodal involvement or distant spread can do very well, with local control rates of up to 90% for cancers under 2-3 centimeters and at least 70% for tumors larger than about 3 cm. We’re still getting a sense of long-term survival, which is often compromised by the other medical problems of patients getting SBRT, but it appears very comparable to limited lung surgery.

Beyond this, there are even a few newer treatments that are potentially available, such as radiofrequency ablation (RFA) or high frequency ultrasound to treat such lesions. They all share a potential to treat an early lung cancer effectively without surgery. To me, the leading question I have is whether they add any real value over the treatments we already have. But they’re evolving, and we’re learning about how they do and whether they might emerge as more effective or safer than SBRT or a VATS wedge resection.

My patient will be meeting with both a surgeon and a radiation oncologist this week to determine which approach he’s inclined to take. Considering that it wasn’t very long ago that such patients had no appealing options, it’s terrific that the field has developed to the point that he now has several choices to consider.