Monthly Oncology Tumor Boards: A Multidisciplinary Approach to Individualized Patient Care - Locally Advanced NSCL Cancer: Stage IIIA Management

August 7, 2014

Join Ross Camidge, MD, PhD, Brian Kavanagh, MD, MPH, and Michael Weyant, MD, as they present their multidisciplinary expertise on a range of cases pertaining to Locally Advanced NSCL Cancer: Stage IIIA Managment.

Most patients (85%) with lung cancer are diagnosed with non-small cell lung cancer (NSCLC). This tumor board will discuss stage IIIA NSCLC, because this is an area with the greatest controversy about treatment. Oncologists need to know the nuances of how to select the best treatment for stage IIIA NSCLC, which can be efficiently shown in an interesting tumor board scenario.   The NCCN Guidelines recommend a multidisciplinary approach for patients with NSCLC to ensure the best possible treatment. It is essential to accurately determine the stage of disease before treatment. Unless patients have obvious metastatic disease, thorough pretreatment staging using imaging (e.g., CTs of the chest and upper abdomen, brain MRI, PET/CT scans) and pathologic mediastinal lymph node evaluation is recommended for most patients so that an accurate clinical stage can be used to guide preliminary treatment planning. Locally advanced NSCLC is stage III using the AJCC staging. Patients with stage III NSCLC have heterogenous disease with different amounts of lymph node involvement; thus, recommended treatment varies depending on the extent of disease. Because imaging studies are associated with false-positive nodes, pathologic confirmation of nodal disease is essential to avoid overtreatment. To confirm mediastinal lymph node status, minimally invasive techniques are now available such as EBUS, EUS, mediastinoscopy, and VATS.
Multimodality therapy is recommended for patients with locally advanced NSCLC; radiotherapy alone or surgery alone is not recommended. Multimodality treatment for stage III NSCLC may range from surgery for microscopic disease (followed by adjuvant treatment) to chemoradiation for bulky unresectable disease. For patients with stage IIIB disease, chemoradiation (not surgery) is typically recommended. Decisions about whether surgery is appropriate for patients with stage IIIA disease should be made by board-certified thoracic surgeons whose practice involves a substantial amount of lung cancer surgery (see Principles of Surgical Therapy in the NCCN Guidelines for Non-Small Cell Lung Cancer). Before surgery, it is essential to determine whether patients can tolerate surgery or whether they are medically inoperable.

Surgery may be recommended for patients with stage III disease followed by adjuvant treatment.  Most surgeons agree that patients with preoperative stage IIIA disease may be candidates for surgery if they have a single N2 lymph node less than 3 cm. However, decision-making is more complicated for patients with multiple N2 nodes. Some patients presumed to have N1 disease before surgery may be found to have N2 disease during thoracotomy and therefore treatment planning may change based on surgical and pathologic results. After surgery, adjuvant treatment using either sequential or concurrent chemoradiation is recommended in the NCCN Guidelines. The type of adjuvant treatment depends on several factors, including whether the surgical margins are positive or negative; whether the resection was R0, R1, or R2; comorbidities; performance status; and patient preferences.

Advances in minimally invasive surgical techniques, imaging, and use of multimodality treatment are transforming the management of locally advanced NSCLC. Recent advances permit the rational development of treatment plans and use of multimodality therapy based on the amount of lymph node disease. Patient and physician discussions should include the importance of careful staging before deciding on a treatment plan. Patients should be aware that surgery may not be appropriate based on the results of testing and that treatment plans may need to be revised based on testing.

Target Audience

This educational activity is designed to meet the educational needs of oncologists, pathologists, nurses, pharmacists, and other health care professionals who manage patients with cancer.

Learning Objectives

Following this activity, participants should be able to:

  • Apply NCCN Guideline-based therapeutic strategies for the treatment of patients with locally advanced non-small cell lung cancer
  • Describe the multidisciplinary aspects of the management of patients with locally advanced non-small cel lung cancer
  • Identify the key characteristics of locally advanced non-small cell lung cancer that trigger decision points
  • Recognize situations where optimal care may require adapting guidelines recommendations to individual circumstances
Additional information
Supporters: 

Supported by educational grants from:

  • AstraZeneca
  • Exelixis Inc.
  • Genentech BioOncology
  • Janssen Biotech, Inc.
  • Novartis Oncology
  • Takeda Oncology

Supported by a grant from Onyx Pharmaceuticals.

Supported by independent educational grants from Merck and Prometheus Laboratories Inc.

Supported by an unrestricted, educational grant from Celgene Corporation.

Course summary
Available credit: 
  • 1.00 Participation
  • 1.00 Nurse
  • 1.00 Pharmacist
  • 1.00 Physician
Course opens: 
08/06/2014
Course expires: 
10/08/2014
Event starts: 
08/07/2014 - 5:00pm
Event ends: 
08/07/2014 - 6:00pm
Cost:
$0.00

Ross Camidge, MD, PhD
University of Colorado Cancer Center

Brian Kavanagh, MD, MPH
University of Colorado Cancer Center

Michael Weyant, MD
University of Colorado Cancer Center

This activity is approved for AMA PRA Category 1 Credit(s)™. Nursing and pharmacy (ACPE) credits are also provided. View complete accreditation information

Available Credit

  • 1.00 Participation
  • 1.00 Nurse
  • 1.00 Pharmacist
  • 1.00 Physician

Accreditation Period

Course opens: 
08/06/2014
Course expires: 
10/08/2014

Price

Cost:
$0.00
Please login or register to take this course.

Required Hardware/software

To complete this activity, users will need:

  • A device with an Internet connection and sound playback capability
  • Adobe Reader or other PDF reader software for certificate viewing/printing