How to Select Treatment for Resectable Stage III Lung Cancer

Mark G. Kris, MD


September 19, 2022

This transcript has been edited for clarity.

It's Mark Kris, continuing my discussion of new therapies for patients with early-stage lung cancers.

I've talked about the questions posed to me by the members of the tumor board at Hartford Hospital. The third question they asked me was, for stage III patients who are resectable and potential candidates for either surgical resection or definitive concurrent chemotherapy and radiation, like in the durvalumab trial, how do you choose among them?

That's a tough question. As you know, the goal here is to cure patients. The group of people we're talking about includes those who are both operable and resectable. I think for those who aren't, it's a clear choice to use concurrent chemotherapy-radiation followed by durvalumab. For those who are both operable and resectable, which one do you choose?

There is no direct comparison with these two approaches. I think they both have been shown to lead to cures. The trial of durvalumab is more mature. There are now 5-year survival data showing an improvement in disease-free survival at 5 years; I would say that's equivalent of cure.

Which do you choose? My bias is surgical, but that's not right for every patient.

Where does surgery make the most sense? I think for larger primary tumors, where the radiation planning and radiation adverse effects could be more problematic, it may make some sense to operate on resectable, larger primary tumors. There is a sweet spot for radiation, and generally, tumors that are smaller are somewhat easier to give a curative dose.

I think the second issue is the availability of resources, staff, and experience at your institution. Many institutions do not have the thoracic surgery capabilities to do these more complicated resections in patients with stage III disease, particularly after neoadjuvant therapy.

There are institutions around the world and the country that do not have the capability to properly plan the radiation and deliver it in a proper way. For those patients, surgery following neoadjuvant therapy may be a better approach. For patients where the surgery may not be available, it may be better to recommend concurrent chemotherapy and radiation followed by durvalumab.

The other issue, of course, is the patient. Many patients are very interested in the concept of surgery. They feel that the resection is something that is very important to them. If it can be done safely and meets the needs and wishes of the patient and their care team, then it makes sense to do an operation.

As you know, my bias is generally to do surgery. I like the ability to completely remove the cancer and definitively stage it. I tend to favor that. Many patients, however, are reluctant to proceed with surgery.

Where there is no certainty that one approach is better than the other, I think the patient's feeling about which treatment is best for them is something that's very, very important, particularly when you have the capability to give either concurrent chemotherapy and radiation definitively or surgery.

Just a quick reminder to please make that decision upfront. There is no track record for any kind of a regimen to take a patient who is not resectable and make them resectable. I would choose the best plan for that patient upfront and follow through in the absence of toxicity or other considerations.

The treatment of locally advanced lung cancer has changed tremendously in the last many months. For patients who do not have a driver [mutation], immunotherapies are the treatments of choice. They can be given in the adjuvant or neoadjuvant setting.

It is very important to make sure our patients do not have a driver. The way to do that and give patients the most options is to do complete testing at the time of diagnosis to see if a driver is present. If it is, you go in one direction. If it isn't, you go in the direction of the immunotherapeutic agent with chemotherapy, either preoperatively or postoperatively.

Results are so much better for patients now. We can offer them more. We can offer them better outcomes. Yet it is much harder for oncologists to make these decisions. We need to make more decisions; however, I think all of us like nothing better than to offer our patients the best chance of cure, which we can do here.

Mark G. Kris, MD, is chief of the thoracic oncology service and the William and Joy Ruane Chair in Thoracic Oncology at Memorial Sloan Kettering Cancer Center in New York City. His research interests include targeted therapies for lung cancer, multimodality therapy, the development of new anticancer drugs, and symptom management with a focus on preventing emesis.

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