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Gregory J. Riely, MD, PhD
Gregory J. Riely, MD, PhD
Posted: Friday, November 15, 2024
Dawn Owen, MD, PhD, of the Mayo Clinic, Rochester, Minnesota, and colleagues observed that neoadjuvant chemoimmunotherapy may be used for patients with unresectable locally advanced non–small cell lung cancer (NSCLC) before chemoradiotherapy to improve local tumor control, since neoadjuvant therapy has improved pathologic response and survival. However, the use of induction therapy causes increased toxicity in many disease sites, which could negatively impactive survival results. Creative clinical management of this type of lung cancer is needed in terms of radiation dose escalation and the incorporation of new agents. Their findings were published in JCO Precision Oncology.
To illustrate the management challenges associated with treating this type of lung cancer, Dr. Owen and colleagues presented a representative case study of a 77-year-old man with a history of chronic obstructive pulmonary disease. For instance, some challenges with nodal staging include the assessment and confirmation of the extent of nodal involvement in patients who present with unresectable locally advanced NSCLC. Many studies have shown the need for combination staging, since there can be a significant number of false-positives and -negatives with PET/CT alone. Given the variability in PET detection of nodal metastases and endobronchial ultrasound mediastinal staging and the potential for occult nodal disease, the researchers concluded that a combination approach may assist in accurate radiation volume delineation. This potential radiologic/pathologic discrepancy may be problematic if relying on PET/CT alone for radiation volumes, according to the investigators.
Furthermore, there have been several modern dose-escalation trials in locally advanced NSCLC to try to improve local tumor control. The results achieved thus far with radiation dose escalation in the absence of immunotherapy have shown that increasing radiation dose globally to the tumor with photon radiation can increase toxicity. Additionally, recent and relevant literature suggests the increased cardiac toxicity associated with dose escalation for patients with lung cancer may contribute to a lower survival benefit.
Disclosure: For full disclosures of the study authors, visit ascopubs.org.
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