Progression of Non Small-Cell Lung Cancer
My husband was diagnosed with stage IIIB adenocarcinoma, which presented with superior vena cava syndrome. He has received radiation treatment concurrent with chemotherapy and is now receiving full strength chemotherapy. We were told at the time of diagnosis that the treatments were to "buy time", not cure. I have searched many web sites, yet I can't find information on what we can expect regarding symptoms and prognosis of cancer progression. Can you give an overview or provide a list of resources, which could help?
Mitchell Machtay, MD, Radiation Oncologist, responds:
Among the most bothersome phrases that I frequently see in oncologists' notes are that the patient "failed radiotherapy," or he/she "failed platin-based chemotherapy," or he/she "failed second-line taxane-based therapy." These statements are not true; it is the treatment that failed the patient. The patient has not "failed" anything and should instead remain proud of his or her individual fight against cancer.
Unfortunately, in locally advanced (inoperable Stage IIIA or IIIB) non-small cell lung cancer (NSCLC), such as adenocarcinoma or squamous cell carcinoma, the treatments often do fail to control the disease. With modern combinations of chemotherapy and radiation, the average survival for people with Stage III NSCLC is approximately 18-22 months – an improvement over the 4-6 month life expectancy for untreated cancer, but still very disappointing. There are certainly some people who can be cured with chemotherapy and radiation therapy for Stage III NSCLC, perhaps as many as 25% of patients with this terrible illness. Unfortunately, cures are seen for patients with stage IIIB in less than 10% of patients, compared with nearly 30% for patients with stage IIIA disease. In what way or ways do our treatments fail to control NSCLC? Broadly, there are two major problems that can occur if treatment fails to control the cancer. One is called "local progression," which means that the tumor continues to grow within the lung and/or into nearby structures such as the ribs, vertebral bodies, or heart. This can cause pain, breathing difficulty, continuous coughing (including coughing up blood), difficulty eating, swelling of the chest, neck and face, and other severe problems. In the worst-case scenario, local progression can lead to death from suffocation or bleeding. The second major problem is "distant progression," which means that metastases (new cancer spots) have shown up in other parts of the body outside of the lung where the cancer started and adjacent lymph nodes, such as to the opposite lung, brain, liver, adrenal glands, bone, or skin. The actual signs and symptoms depend on exactly where the cancer has spread: for example, spread to the brain can cause headaches, nausea, confusion, visual changes, difficulty with motor strength or balance, change in sensation, or other symptoms similar to a stroke. The primary objective of radiation therapy (with or without chemotherapy at the same time) is to prevent or at least delay local progression. The primary objective of "full dose" chemotherapy (given either before or after radiation) is to prevent or at least delay distant progression.
Additionally, some people with NSCLC might not have any obvious signs of local or distant progression, yet they still develop life-threatening complications from their cancer or their recent treatment. These problems can include infections, pneumonia, dehydration, malnutrition, poor blood circulation (including blood clots), or just extreme weakness and weight loss called "failure to thrive." If someone with lung cancer starts feeling much worse, it is important to undergo testing to see if his or her cancer is progressing. If the cancer is not progressing, aggressive medical treatments and perhaps a brief hospitalization can sometimes completely reverse the active problem at hand. If the cancer is progressing, it can be much more difficult, but still possible, to help ease the symptoms.
Local progression can be very difficult to treat, but in select cases, with aggressive management, cure may still be possible with surgery or even thoracic reirradiation. If distant progression has occurred, life expectancy is usually not very long. Nonetheless, there are still many treatments that may be able to prolong survival and can also improve quality of life, called palliative therapies. Occasionally, this may include "conventional" treatments such as additional radiation therapy and/or chemotherapy. An alternative may be to join a clinical trial studying a new or experimental therapy. However, many patients who have experienced distant progression of cancer after chemoradiation for Stage III NSCLC are not strong enough for or simply do not want second or third line anti-cancer treatments. For these individuals, a menu of supportive treatments exists and can be very helpful. These might include prescription medications to ease pain, nausea, anxiety and depression; home oxygen therapy; nutritional supplements; home mobility equipment (such as an adjustable bed or wheelchair); and psychosocial and/or spiritual counseling. Many of the needs of the patient and his or her family in this difficult time can be met by a comprehensive home Hospice Program. In some ways, there have been more advances over the past 30 years in supportive care than there have been in "traditional" surgery, radiation therapy, and chemotherapy, and the hope for a comfortable end of life should never be given up.
For more information, I would recommend asco-online (www.asco.org). Among their resources is an online guide called Advanced Lung Cancer. Also, consider the web-site for one of the country's major lung cancer patient advocacy group, Lung Cancer Alliance. Many Metropolitan areas also have local organizations providing or championing supportive services. For more information about hospice and end-of-life care, try the Hospice Foundation.