Posted: February 2, 2018

Many people operated on for lung cancer recur either in the chest near the original tumor, or with metastatic disease elsewhere.  It is possible to predict who they will be statistically: those with a lot of positive lymph nodes, and those whose tumors could not be completely resected based on pathology review after the operation is complete; even though the surgeon may have thought he “got it all” there is tumor at the margin of resection.  So what should be done?  Modern thinking is that  chemotherapy and possibly radiation should be given after surgery.  Then the question is: should they be given together or sequentially?  A new study purports to answer that question.

In the Journal of Clinical Oncology, the official journal of the American Societyof Clinical Oncology, comes a study from the Huntsman Cancer Institute at the University of Utah.  The authors looked at two different ways of treating these patients: either chemo first followed by radiation, or giving the two together.  They amassed about a thousand cases for analysis.  It’s important to note that this was not a randomized study, but rather a retrospective review.   In a randomized trial patients would be randomly allocated to one of two or more treatment options at the beginning of their treatment.  In a retrospective review, all patients have already completed treatment and how they did is looked at with benefit of hindsight.

What the authors found was that for patients whose tumors could be completely resected but had extensive lymph node involvement (N2 or mediastinal nodes) sequential chemotherapy followed by radiation offers a significantly better outcome than giving the two together.  For the complete article, please send Dr. Stark a request using the form on the right.  For patients whose tumors grew to the edge of resection — either discovered by the pathologist or acknowledged by the surgeon at the end of the case — it didn’t make a significant difference how the treatments were applied.   The medial overall survival in patients completely resected who received sequential therapy was 58 months; for all other groups it was about 40 months.

So what do we learn?  Dr. Stark comments: the value of this study is in a small group of patients but for them it appears that sequential therapy is best.  The development of powerful new lung cancer drugs will likely make these results moot very shortly, however, and that is a good thing.