Insights From: Dirk De Ruysscher, MD, PhD, Maastricht University Medical Center
Dirk De Ruysscher, MD, PhD: Radiation treatment can actually be given to all stage III disease in general. But of course, stage III non–small cell lung cancer is very heterogeneous, not only because the patient can be very heterogeneous because of the performance status, but also the anatomical location can be very different. We see some patients with stage III disease who have a total volume of the tumor and the lymph nodes of say something like 50 mL, and some patients at diagnosis have between 300 mL and 400 mL. But the average patient has a volume of tumor of about 120 mL, and that’s quite large.
Depending on the location of the lymph node or the volume of the primary tumor, you can offer them radiation with chemotherapy most of the time. Sometimes you also add surgery, certainly when the volume of the tumor is 5 cm or more, something like that, or has already some excavation, so central necrosis, which leads to oxidation. And when you treat them with radiation, sometimes you don’t have an alternative, then this may lead to oxidation, to chronic infection, and it’s of course even lethal in some cases.
Most of the time we can treat those patients with radiation. There’s no added value for surgery, and that has been shown in randomized studies, unless in specific cases like I mentioned. On the other hand, we treat the patients, if possible, also with systemic treatment because, at the time of diagnosis, even though it’s not detectable by CT [computed tomography] scans, about 80% have already distant metastasis. That’s the reason why it’s so important to integrate systemic treatment with radiation.
Patients with lung cancer frequently have poor performance status and that is because patients have smoked a lot. Most of the time they smoked between 30 and 60 packs a year, so a lot of those patients have lung emphysema, have heart disease, have stroke. So all those things happened before in those patients, and because of that they frequently have a poor performance status. Performance status is defined as a WHO [World Health Organization] score of 2 or more, and it’s very difficult to know exactly what we should do with those patients.
The only thing what we do know for sure is that you shouldn’t harm them too much and probably is best not to treat them with concurrent chemotherapy and radiation. It’s probably better to give them chemotherapy followed by radiation, the so-called sequential approach. In some cases it’s probably also better to treat them palliatively, certainly in the case of performance status 3 or 4. Because if you treat them aggressively, you induce so much toxicity that not only the quality of life is very bad, but probably you will really kill some patients by treating them too aggressively. So it’s much better to give them sequential chemoradiation or radiation alone.