Frequently Asked Questions
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Current standards of care include:
- Intensity-Modulated Radiotherapy (IMRT): Complex radiation beams that sculpt radiation dose volume to precisely conform to geometric target, sparing adjacent organs at risk. IMRT is associated with a reduced risk of severe pulmonary toxicity and radiation exposure to the heart, and a statistically significant improvement in OS, when compared to patients treated with 3D conformal radiotherapy. IMRT is a radiation technique as part of chemoradiation-based care1-4
As more treatment options have become available, choosing an appropriate treatment strategy has become more complex. Patients with Stage II to III NSCLC may be eligible for either established curative intent pathway (surgery-based or chemoradiotherapy-based). Therefore, careful patient selection on a case-by-case basis is critical for ensuring that each patient receives the approach that is most appropriate for them and their cancer.5
Adverse events change over time and in intensity over the course of CRT, so it is important to manage them proactively6,7
- Radiation-induced adverse events have different times of onset and vary in severity throughout CRT–for example, head and neck AEs, like esophagitis and difficulty swallowing, generally manifest during weeks 2 to 3 and increase over time
- Many adverse events can resolve between 2 to 4 weeks after completion of CRT, but some may take months
- Given the variation in adverse event presentation and timing, it’s important to stay vigilant and proactively manage any adverse events as they arise
Strategies that may help ensure CRT is uninterrupted and completed include8,9:
- Selecting a more tolerable chemotherapy regimen. Etoposide-cisplatin and carboplatin-paclitaxel have shown similar OS; however, carboplatin-paclitaxel has been associated with fewer toxicities
- Initiating chemotherapy prior to RT
- Closely monitoring and managing CRT-related AEs
- Encouraging your patients to report AEs to their healthcare provider
Videos
Talking to Patients About a Perioperative IO-based Regimen
Dr Sepesi:
Welcome to Beyond the Blade. I’m Dr Boris Sepesi. I’m a thoracic surgeon at Sarah Cannon Cancer Network, HCA HealthONE in Englewood, CO.
Dr Sepesi:
In this video, we’ll discuss an important role for community surgeons in early stage non-small cell lung cancer.
Dr Sepesi:
Perioperative IO-based regimens with neoadjuvant IO plus chemotherapy before surgery and adjuvant IO after surgery have recently been approved for use in early stage non-small cell lung cancer.
Dr Sepesi:
It’s increasingly important for surgeons in community practices to know that these regimens are FDA approved for resectable non-small cell lung cancer and what the implications are for their practice, including the need to refer appropriate patients to a medical oncologist to discuss this treatment option prior to surgery.
Dr Sepesi:
To discuss this, we have gathered academic and community surgeons with diverse surgical backgrounds and experiences with IO plus chemo before and IO alone after surgery.
Dr Khandhar:
I’m Sandeep Khandhar. I’m a thoracic surgeon at the Virginia Cancer Specialist Practice in Northern Virginia.
Dr Okusanya:
I’m Olugbenga Okusanya. I’m a thoracic surgeon at Thomas Jefferson Health.
Dr Sepesi:
Patients put a lot of trust in surgeons. They don’t necessarily understand the biology of cancer the way we do and therefore it is important for us to guide patients throughout the entire course of therapy rather than just through the surgical treatment.
Dr Khandhar:
When we talk to patients about lung cancer resection, we are often the last appointment. They’ve seen pulmonology, radiology, medical oncology, sometimes radiation oncology before they come to us. And tensions are always very high. They want their tumor cut out and they want it cut out right away. Sometimes just removing that tumor and cutting it out is not always the best option. We know that recurrence rates are high.
Dr Okusanya:
I think it’s really important to talk to our patients about what their available options are. The last thing you would ever want is a patient to leave your clinic, see a commercial, and then come back to you and say, “Hey, what about this option? Is that something I’m a candidate for?”
Dr Okusanya:
So, engaging your patients in a conversation about any particular option, I think is reasonable, even if you don’t think that’s the option that they should take. But maybe in the case of a perioperative IO-based regimen, that’s the one they should take. So, I think making sure to take the time to have an open discussion and build a relationship with your patient is really critical in order to move forward.
Dr Sepesi:
Here are key ways to talk to your patients about a perioperative IO-based regimen.
Dr Khandhar:
Number one. Immunotherapy plus chemotherapy before surgery works in two ways. In preclinical models, it activates your body’s own immune system to find and attack those cancer cells and destroys rapidly growing cancer cells. Additionally, giving immunotherapy after surgery may help remove any remaining cancer cells. IO may also affect normal, healthy cells.
Dr Okusanya:
Number two. Perioperative regimens are one of the latest advances in lung cancer treatment for early-stage non-small cell lung cancer and have been studied in several major clinical trials.
Dr Khandhar:
Number three. A perioperative IO-based regimen requires a team of specialists, instead of just one physician, to focus on you and your lung cancer. This ensures that your situation and all treatment options are discussed by all relevant specialties so you can receive the best possible care.
Dr Okusanya:
Number four. With a perioperative IO-based regimen, as with all cancer treatments, you, as the patient, are the most important member of your care team. You should feel free to ask all the questions you have of the other members of the care team so that you’re confident in the treatment you’re receiving.
Dr Khandhar:
Number five. A perioperative IO-based regimen provides the opportunity before surgery to make important lifestyle changes such as quitting smoking, exercising, and other activities that might improve how you do with surgery.
Dr Okusanya:
Number six. Perioperative IO-based regimens are recommended by lung cancer experts and treatment guidelines for appropriate patients with resectable non-small cell lung cancer.
Dr Khandhar:
Number seven. With surgery, our goal is curative intent. Perioperative IO-based regimens are the latest advance in the curative intent setting of resectable non-small cell lung cancer.
Dr Sepesi:
Doctors, thank you for sharing this helpful information for community surgeons to share with appropriate patients. I think it’s important to emphasize that perioperative IO-based regimens are FDA approved and becoming a standard of care for resectable non-small cell lung cancer. They’re also recommended by thoracic surgery guidelines as well as other treatment guidelines.
Dr Sepesi:
It is critical that all community surgeons have open conversations with their patients and refer them to medical oncologists prior to surgery to ensure patients can make informed decisions on what treatment is best for them.
Dr Sepesi:
Thanks for watching. Be sure to “like” the video and subscribe to this channel for more expert insights.
5 Reasons for Using a Perioperative IO-based Regimen
Dr Sepesi:
Welcome to Beyond the Blade. I’m Dr Boris Sepesi. I’m a thoracic surgeon at Sarah Cannon Cancer Network, HCA HealthONE in Englewood, CO.
Dr Sepesi:
Perioperative IO-based regimens with neoadjuvant IO plus chemotherapy before surgery and adjuvant IO after surgery have recently been approved for use or are being studied in early-stage non-small cell lung cancer.
Dr Sepesi:
It is important for all community thoracic surgeons to know about these regimens and what we are going to discuss today are reasons for the use of these perioperative IO-based regimens.
Dr Sepesi:
To discuss this, we have gathered academic and community surgeons with diverse surgical backgrounds and experiences with IO plus chemo before and IO alone after surgery.
Dr Khandhar:
I’m Sandeep Khandhar. I’m a thoracic surgeon at the Virginia Cancer Specialist Practice in Northern Virginia.
Dr Okusanya:
I’m Olugbenga Okusanya. I’m a thoracic surgeon at Thomas Jefferson Health.
Dr Sepesi:
There are known risks with a perioperative regimen from the potential for surgical delays, patient attrition, complications from the systemic treatment, etc.
Dr Sepesi:
In my practice, I really try to communicate with medical oncologists, and we also utilize nurse navigators to really follow these patients even while they’re getting their neoadjuvant therapy to make sure that they are going through the process safely, to really learn about how they’re tolerating the regimen as we plan the operations.
Dr Okusanya:
I think it’s really important for thoracic surgeons to know this because I personally remember seeing a patient with an early-stage lung cancer who was going to be a candidate for these strategies that could help her in her pathway. And I think it’s really important for all surgeons, all community surgeons, academic surgeons to be able to have these options to present to their patients.
Dr Sepesi:
Here’s our list of our reasons for using perioperative IO-based regimens. Dr Okusanya, please get us started.
Dr Okusanya:
Number five. Like to be at the forefront of treatment advances? Perioperative IO-based regimens are one of the latest treatment advances and are becoming a standard-of-care for appropriate patients in the curative-intent setting of resectable non-small cell lung cancer.
Dr Khandhar:
Number four. Resectable non-small cell lung cancer is heterogeneous and often involves micrometastatic disease. Cancer cells that spread beyond the tumor may lead to recurrence after surgery. It is hypothesized that an IO regimen before surgery may reduce tumor burden prior to definitive therapy and may target circulating cancer cells, while IO after surgery may target any remaining cancer cells.
Dr Okusanya:
Number three. Many of the patients who have heard about perioperative regimens as a treatment option may appreciate learning from us how an IO regimen works with their body’s own immune system to activate T cells before surgery to fight the cancer and how it works after surgery to continue to destroy cancer cells. It is also important to tell them that an IO may also affect healthy cells.
Dr Khandhar:
Number two. My reasons for treating patients with an IO-based regimen before surgery are that performance status should be ideal and compliance rates with systemic therapy may be higher. The time before surgery also provides the opportunity for patients to incorporate lifestyles modifications, such as short-term smoking cessation and pre-surgery exercise, that may help improve performance status and outcomes.
Dr Okusanya:
Number one. Despite our best efforts with R0 resections, only about a third of patients with resectable non-small cell lung cancer are alive at 5 years. Patients with resectable non-small cell lung cancer may require a multimodal approach that’s inclusive of surgery and systemic therapy, such as with an IO-based regimen before and after surgery. Referring these patients to a medical oncologist and collaborating with them is key for helping them make an informed treatment decision.
Dr Sepesi:
Doctors, thank you for sharing this list. I think it’s important to emphasize that perioperative IO-based regimens are becoming a standard-of-care for resectable non-small cell lung cancer and recommended by surgical societies and various treatment guidelines.
Dr Sepesi:
Surgeons should refer all appropriate patients to medical oncologists and truly collaborate with them, communicate with them even on treatment decisions.
Dr Sepesi:
Thanks for watching. Be sure to “like” the video and subscribe to this channel for more expert insights.
Considerations for Optimizing CRT: Patient Cases
Watch the lung cancer MDT at AdventHealth discuss diagnosis and staging for optimal NSCLC care.
Featuring: Dr Fortune Alabi, Pulmonologist; Dr Chung-Che (Jeff) Chang, Molecular Pathologist; Dr Charles (Wes) Hodge, Radiation Oncologist; Dr Tarek Mekhail, Medical Oncologist; Dr Mark Socinski, Medical Oncologist Brenda Rzeszutko, Nurse Navigator
Narrator:
Considerations for optimizing CRT in NSCLC: Patient cases.
Narrator:
The views and opinions expressed in this video are those of the individual oncology specialists and do not represent the views or opinions of AstraZeneca. This video contains anecdotal information gathered from a discussion with oncology specialists based on their opinions/experiences. Recommendations are general and may vary with patients. At the time of this filming, the Healthcare Professionals featured were in the roles and at the institutions indicated.
Narrator:
Here, we’ll present a team discussion of three cases of patients diagnosed with NSCLC. One with T3N2, one with T3N3 and one with EGFR mutated T4N3.
Dr Subramanian:
Hello, I’m Dr Janakiraman Subramanian. Welcome to our video series on the changing landscape of unresectable Stage III non-small cell lung cancer. In this video, we’ll be discussing 3 cases of patients with unresectable Stage III non-small cell lung cancer.
Dr Mahajan:
My name is Bobby Mahajan, and I’m an interventional pulmonologist.
Dr Chun:
I’m Stephen Chun. I’m a radiation oncologist.
Dr Sepesi:
Hi, I’m Dr Boris Sepesi. I’m a thoracic surgeon.
Narrator:
Here is case #1, a patient with Stage IIIA T3N2 NSCLC.
Dr Subramanian:
Let’s look at our first patient here.
Dr Subramanian:
So, this is Alan, who presented to his primary care with a prolonged and productive cough. He’s 67 years old and a former tobacco smoker with a 40-pack-year smoking history. And this cough has been of prolonged duration and it has not improved despite taking some over-the-counter medication. He does have some additional medication comorbidities like hypertension and asthma, but good performance status ECOG PS at 1. And he had an initial chest X-ray done, which shows a single mass in the lung, and that’s concerning obviously, for malignancy. And so, his primary care refers him to a pulmonologist for further evaluation.
Dr Subramanian:
So, Bobby, when you see a patient like this, how does the referral pattern work? How do these patients get referred to you?
Dr Mahajan:
The referral patterns are multiple. Sometimes we see nodules that are incidentally found, for example, in a patient who might just have a cough or comes to the ER and they get a chest CT, then shows a lung nodule. Other ways we see our patients who have symptoms associated with possibly larger masses or through lung cancer screening. They are sent to multiple different physicians before they get typically to the right physician or to the multidisciplinary meeting.
Dr Subramanian:
That is a challenge for our patients.
Dr Subramanian:
So, this patient, when he is seen by his pulmonologist, gets a PET/CT and also has PFTs, and a bronchoscopy done as well. The CT scan identified right lower lobe lung mass measuring four centimeters and invading the chest wall. And on the PET/CT, not just the primary tumor, which was FDG-avid, also the hilar and mediastinal lymph nodes had increased FDG uptake concerning for cancer. So, PFTs are reasonably good—DLCO at 70%, FEV1 at 70%. Bronchoscopy was done with EBUS, and he has both the tumor as well as the lymph nodes are positive for malignancy. And at this point, this patient was referred to see a medical oncologist.
Dr Okusanya:
Number four. With a perioperative IO-based regimen, as with all cancer treatments, you, as the patient, are the most important member of your care team. You should feel free to ask all the questions you have of the other members of the care team so that you’re confident in the treatment you’re receiving.
Dr Subramanian:
Are there any tests you would get at this point, Bobby, for this patient?
Dr Mahajan:
Even though the easiest way to approach this might be just do a needle biopsy of the nodule, it provides us with a diagnosis, but it does not provide us with all the data we need. We really need to be able to stage these patients, see if there’s N2 disease or N1 disease, if it’s single station or multistation. We would want to be able to send this over to our medical oncologist and a radiation oncologist. At that point, then talk to our navigators about getting a PET/CT, a brain MRI so that again, when they hit the medical oncologist’s office, all that data is already obtained.
Dr Sepesi:
I definitely think that the biomarker testing should be done essentially immediately at the time of diagnosis. The biological behavior over here is aggressive. I would certainly not recommend an upfront operation in this situation. I think this patient should definitely be treated up front with either systemic therapy or potentially just go the pathway of concomitant chemoradiation. But this is where the biomarkers, they must be done in order to make this decision in terms of is this EGFR or ALK positive and what is the PD-L1 status?
Dr Subramanian:
So, Bobby, what are you looking for when you have a really tiny sample in the initial biopsy, or you think it may not be adequate for molecular testing. What do you do to mitigate that?
Dr Mahajan:
Well, I think that in a lot of ways, we have to use all the resources available to our disposal. Really, it is important to take your time, biopsy at least 2 malignant nodes if present so that oncologists and the pathologist especially can choose between different cell blocks on which sample should be sent for NGS to get the best chance of actually getting a full panel back.
Dr Subramanian:
Boris, in your opinion, do you think this patient is resectable or borderline resectable? And overall, how do you manage patients with Stage III N2 disease?
Dr Sepesi:
I think that I would classify this patient as a borderline resectable because he has a primary tumor that’s abutting, at least the parietal pleura. And certainly, it seems that the nodal disease is already spreading from N1 station to multistation N2 disease. From anatomical standpoint, I think that this operative field sort of encompasses the entire visible disease on the CT scan. And therefore, I would believe that in my hands, this is still potentially a resectable disease; however, with the caveat of the way this disease is acting biologically, and this is why I would to know the biomarkers prior to this as well, as I would discuss this patient in a multidisciplinary setting for different neoadjuvant or other treatment options or options for nonsurgical options as well for concomitant chemoradiation.
Dr Chun:
I want to also echo Dr Sepesi’s comments and emphasize the importance of reflexly getting biomarkers. I also want to discuss a potential situation of a patient like this receiving neoadjuvant therapy. I would argue for involving the radiation oncologist up front before making that determination, because it’s possible, like in this case, that a radiation treatment volume could be developed safely that did not require neoadjuvant therapy. I want to emphasize that even in tumors that, let’s say, do not respond to neoadjuvant therapy or even, let’s say, suddenly progress on neoadjuvant therapy, that does not necessarily mean that it would not respond to concurrent chemoradiation. That’s a great pearl of wisdom I learned from the great Wally Curran, actually—just because someone doesn’t respond to chemotherapy doesn’t mean that they won’t respond to chemoradiation. But my preference is that radiation be involved very early on and before decisions are made regarding neoadjuvant therapy.
Narrator:
In summary, this Stage IIIA patient was deemed borderline resectable. MDT communication was crucial in formulating the treatment plan. Understanding this patient’s biomarkers was an important part of appropriate treatment planning.
Narrator:
This is case #2, a patient with unresectable Stage IIIC T3N3 NSCLC.
Dr Subramanian:
So, here we have our second patient who’s a former tobacco smoker presenting with cough and diagnosed with a lung mass or a lung opacity on the right side on her chest X-ray. Good performance status. So, she has a CT scan, which shows 5.2-centimeter, right middle lobe mass. And the lesion or the tumor is FDG-avid on the PET scan. And then she has a CT-guided biopsy that shows that this is a non-small cell lung carcinoma, and they also get an MRI of the brain done, and she has a tumor board discussion on this case as well.
Dr Subramanian:
So, looking at this particular case, Stephen, what do you see as some of the challenging issues when you look at the PET scans?
Dr Chun:
So, looking at this particular case, I think what jumps out at probably all of us here is the extent of disease and whatever local therapy, I don’t want to speak for surgery, but whatever local therapy is going to be used, this is a very large area that needs to be locally controlled. From a radiation standpoint, it is very important to have the best imaging possible so that we can make the radiation treatment fields as conformal and specific to the patient anatomy as possible. It’s also very important for the patient to be optimized in terms of nutrition, in terms of side effect management, because there’s going to be a very large amount of esophagus exposed to radiation. And also, I think very close coordination with medical oncology where concurrent chemotherapy would be administered. I also want to emphasize, this case, when I look at the PET scan, we see supraclavicular nodes or N3 nodal disease. I just want to emphasize because I see this sometimes confused in some of my examinees, but this is Stage III disease. It’s not Stage IV. And a patient like this, while treatment may be very challenging, these patients are very much candidates for curative intent chemoradiation followed by appropriate consolidative therapy based upon their molecular profile. In this situation, surgery made a determination this was not appropriate for a resection with what we see here, bilateral mediastinal metastasis, right supraclavicular nodal metastasis, and a fairly locally advanced right middle lobe tumor.
Dr Subramanian:
So, Boris, what are the clinical characteristics that you look for in determining whether a patient is either technically resectable as well as whether they are medically operable?
Dr Sepesi:
This is actually that interesting case that as I look at it as a surgeon. So, on one hand, middle lobe is the smallest of all lobes; it’s only two segments, contributes 10% to lung function. This tumor is already pretty much including the entire middle lobe. So, from the pulmonary standpoint, removing the lobe probably would not be that morbid for the patient. But the deal-breakers over here for me is certainly the contralateral disease and supraclavicular disease, because that’s a disease distribution that is outside of the field, it’s outside of the incision that I would make. I can certainly take out the node, but I cannot control the disease and therefore I would not want to do a disservice to this patient even though this patient was technically operable. I am unable to achieve complete resection of all visible disease and therefore, I think this patient would be best served with my colleagues from radiation and medical oncology.
Dr Mahajan:
We have to look at all the collateral issues that could come not only before and after treatment. So I think that when we have everyone on the same page on a regular basis, looking at not only what are we going to do today, but what are we going to do two, three months from now, in this case, no appreciable disease as opposed to surgical care.
Dr Chun:
So, for a patient like this, at my institution, radiation oncology would be involved up front. Now, that being said, not every institution has a upfront multidisciplinary evaluation, but I would think that very shortly after finding that this is N3 nodal disease—let’s say the patient’s seen a surgeon—I would be surprised if a radiation oncologist wasn’t involved at that point.
Narrator:
In summary, this patient has unresectable Stage IIIC NSCLC. Patients with unresectable Stage III NSCLC can be candidates for curative intent CRT followed by consolidation therapy. Radiation oncology should be involved early in determining the appropriate treatment plan.
Narrator:
Here is case #3, a patient with unresectable EGFR-mutated Stage IIIC T4N3 NSCLC.
Dr Subramanian:
So, we are here with our final case for this program. So, we have Henry, who’s a 68-year-old retired police officer and who presents with cough and shortness of breath. And he is a former tobacco smoker, but quit long back, and he basically presents to his primary care.
Dr Subramanian:
So, we do know that he has lung cancer because he has a PET/ CT—there you can see a hypermetabolic mass with mediastinal adenopathy—has an EBUS and the biopsy was positive for lung adenocarcinoma. No intracranial metastases is what we have. And he is highly motivated in getting a curative intent treatment.
Dr Subramanian:
So, knowing this particular case, Stephen, what would you recommend as his frontline treatment?
Dr Chun:
So, again, I think in alignment with what we were discussing earlier, the importance of doing reflex biomarker testing. I would want to have that information before proceeding with treatment. So I’d want a surgical opinion. I’d want invasive staging to determine the lymph nodes that were positive. And I would also want just baseline information, MRI of the brain, full staging workup before proceeding.
Dr Subramanian:
So, to you, Bobby, at what point would you consider biomarker testing for Henry?
Dr Mahajan:
So, looking at this case, I would recommend biomarker testing immediately upon diagnosis and getting tissue.
Dr Subramanian:
As a medical oncologist, the first thing I’m looking is whether they have the biomarker testing done. So Stephen, when you are seeing a patient like this, when do you typically see the biomarker results becoming available to you?
Dr Chun:
If there’s some kind of a delay, something that is unresectable, determined to be unresectable, whether or not there is a biomarker like EGFR or PD-L1 or ALK, the initial standard is still concurrent chemoradiation.
Dr Subramanian:
In your institution, who orders the testing?
Dr Sepesi:
So, medical oncologists have been kind of in charge of that, but we are really right now trying to educate everyone, so surgical teams as well as pulmonologists. And again, we really try to involve navigators to help to make sure that this is done. I honestly think that it should be done reflexively by pathologists. I think that is the most efficient way of doing this.
Dr Narrator:
In summary, this patient has unresectable Stage III EGFRm NSCLC. All eligible patients should receive biomarker testing around the time of diagnosis. CRT is part of standard-of-care treatment in unresectable NSCLC.
Dr Subramanian:
So, this brings us to the end of our discussion on patient cases with unresectable Stage III non-small cell lung cancer. I believe they’ve helped highlight the importance of MDT communication and collaboration, as well as the increasing importance of biomarker testing for ensuring optimal clinical and treatment decisions in this setting.
Diagnosis and Staging of Unresectable Stage III NSCLC
Watch the lung cancer MDT at AdventHealth discuss diagnosis and staging for optimal NSCLC care.
Featuring: Dr Fortune Alabi, Pulmonologist; Dr Chung-Che (Jeff) Chang, Molecular Pathologist; Dr Charles (Wes) Hodge, Radiation Oncologist; Dr Tarek Mekhail, Medical Oncologist; Dr Mark Socinski, Medical Oncologist Brenda Rzeszutko, Nurse Navigator
Narrator:
Diagnosis and staging of unresectable Stage III NSCLC.
Narrator:
The views and opinions expressed in this video are those of the individual oncology specialists and do not represent the views or opinions of AstraZeneca. This video contains anecdotal information gathered from a discussion with oncology specialists based on their opinions/experiences. Recommendations are general and may vary with patients. At the time of this filming, the Healthcare Professionals featured were in the roles and at the institutions indicated.
Narrator:
Topics discussed in this video include: Ensuring a complete diagnosis. Imaging and pathological staging. Testing. And determining resectability.
Dr Subramanian:
Hello, I’m Dr Janakiraman Subramanian, I’m a medical oncologist. Welcome to our video series on the changing landscape of unresectable Stage III non-small cell lung cancer. In our first video of this series, we’ll be talking about the diagnosis and staging of unresectable Stage 3 non-small cell lung cancer.
Dr Mahajan:
Thank you, Ram. My name is Bobby Mahajan, and I’m an interventional pulmonologist.
Dr Chun:
And I’m Stephen Chun. I’m a radiation oncologist.
Dr Okusanya:
I’m Olugbenga Okusanya. I’m a thoracic surgeon at Thomas Jefferson Health.
Dr Sepesi:
Hi, I am Dr Boris Sepesi. I’m a thoracic surgeon.
Dr Roy:
Hi, and I’m Megan Roy. I’m an oncology nurse navigator.
Narrator:
Our first topic is ensuring a complete diagnosis, focusing on imaging and pathological staging.
Dr Subramanian:
What do you think is needed for a complete diagnosis of unresectable Stage 3 non-small cell lung cancer?
Dr Mahajan:
In a perfect world, all eligible patients with lung cancer would be referred to a multidisciplinary oncology team so that oncologists and thoracic surgeons can discuss the case in detail and determine treatment options and resectability.
Dr Mahajan:
At our institution, a complete diagnosis occurs when the appropriate biopsy is led and we’ve performed the lung lesion to diagnose and stage the patient in one procedure. Patients may see various physicians such as pulmonologists, oncologists, interventional radiologists, who are unable to provide the complete diagnosis and stage all at one procedure.
Dr Mahajan:
This approach optimizes efficiency for patient care and reduces time from identification to treatment. Once the patient is seen by the thoracic surgeon following complete diagnosis and staging, the thoracic surgeon would conduct a full workup to determine initial resectability. That workup should include a medical history, physical examination, assess comorbidities and performance status, order chest CT scans, and check labs, PFTs, EKGs, et cetera.
Dr Subramanian:
As the nurse navigator for the thoracic oncology program, how do you see your role in making sure that the patients have the appropriate diagnosis and staging for their unresectable Stage 3 non-small cell lung cancer?
NN Roy:
So, a lot of times, the nurse navigator is the first contact a patient has after finding out they have an abnormal CAT scan. So, we play a crucial role of reviewing the records, making sure we get the images there, and then setting them up with our pulmonology team or our thoracic surgeons to try to get that process as seamless as possible and get them in as quick as possible.
Dr Subramanian:
I agree fully with what you said. In my experience, I’ve found that nurse navigators are the glue that hold our multidisciplinary team together and are essential for helping our patients through their lung cancer journey.
Dr Subramanian:
When you do your diagnosis and staging, when do you get your PET CT and your brain MRI scans ordered? When do you think they should be done?
Dr Mahajan:
In my experience, I consider the whole body PET and brain MRI to be essential for determining the appropriate care pathway after bronchoscopy and mediastinal staging are performed. The false-negative rate of determining mediastinal involvement of malignancy can be as high as 15% to 20%, so a PET should not be the only means of staging. This only provides a clinical stage. Instead, combining an EBUS bronchoscopy with clinical staging through PET should be performed, and that EBUS will allow us to sample mediastinal nodes at the same time as obtaining a diagnosis. The PET should be used only for evaluation of distant metastases, not as a primary means of staging.
Dr Sepesi:
I also think that it’s important to point out that not every community setting has the expertise of very skilled interventional pulmonologists like Dr Mahajan to do the transbronchial biopsies and staging via EBUS, so maybe using the latest robotic technology. And oftentimes surgeons will also act as perhaps interventional pulmonologists or they act as surgeons to obtain diagnostic tissue.
Dr Subramanian:
Even more reason for the specialists that are available to be talking to each other, especially the medical oncologist, the surgeon, and the pulmonologist, to ensure a complete diagnosis.
Dr Chun:
In lung cancer, we know that clinical staging with imaging as well as pathologic staging are both necessary to complete staging. While imaging with CT scans, PET scans, and certainly MRIs of the brain are crucial steps, they often only tell part of the story with respect to the status of pulmonary mediastinal lymph nodes and a bronchial tumor extension, et cetera.
Dr Chun:
I’d like to share that as we speak, I have a patient being treated who we initially thought had T3 N0 disease, which we were going to treat conceivably with radiation alone. Because of the bronchoscopy, they found an N1 or hilar node, which meant the difference between including that tumor in the radiation field or not, but also the addition of concurrent chemotherapy, which obviously has an enormous impact on that patient’s outcome. And so the more accurately we can characterize the stage of patients, the better we can ensure that they’re treated correctly.
Dr Subramanian:
Why is it important to have a multidisciplinary discussion prior to determining resectability?
Dr Sepesi:
I think that it is extremely important to have multiple providers meet, especially at these more challenging tumors. And so this way we all come together and we can analyze the case to see what’s in patient’s best interest with the least amount of morbidity, but the highest efficiency for the treatment.
Narrator:
This next section covers testing as part of ensuring a complete diagnosis.
Dr Subramanian:
In early-stage as well as locally advanced non-small cell lung cancer, checking for driver mutations of the tumor is now crucial because that can affect the treatment plan for these patients.
Dr Subramanian:
What approach do you take when you are sampling these tissue? What are the key factors you’re looking for to ensure you get an adequate tissue sample when you do the biopsy?
Dr Mahajan:
In my practice, tissue is always the issue. Lung cancer is not just diagnosing, but also getting next-generation sequencing. So you don’t just check to see if it’s adenocarcinoma or a nonsquame, but there are biomarker tests that need to be obtained with required adequate tissue and allows us to make decisions later on in the care continuum.
Narrator:
Our next topic is determining resectability in NSCLC.
Dr Sepesi:
I think the thoracic surgeon is really crucial in actual treatment of lung cancer, and this is not just Stage 1, but Stage 2, Stage 3, making decisions regarding resectability and operability of those patients.
Dr Subramanian:
So I specifically look at the size of the tumor, location of the tumor, location of the tumor to the chest wall, to visceral pleura, parietal pleura, other lobes. I look at whether this would be resectable with sublobar resection, lobectomy, or pneumonectomy because all of this has impact in terms of how much lung function we preserve.
Dr Sepesi:
The word operability truly relates to patient’s physiologic status. For example, their pulmonary function testing, their cardiovascular status, their resilience, their exercise ability. In my opinion, some patients may be too frail for surgery. And so those patients should most likely not be operated on even though they technically, potentially could be resectable, and then they’re deemed “unresectable” in this setting. And I believe that surgical planning and treatment planning should truly be based on the initial disease distribution, and those decisions should be made up front in a multidisciplinary setting.
Dr Chun:
And I’m in total agreement with Dr Sepesi on the importance of multidisciplinary evaluation to determine operability. Really, a number of factors that are involved here, including tumor anatomy, patient age, performance status, comorbidities—all of these things can impact how a patient’s going to do after surgery. These characteristics sometimes have a bearing because morbidity following an invasive surgery, as Dr Sepesi alludes to, might not be worth the benefit of removing the tumor invasively.
Narrator:
In summary, the main takeaways from this discussion include the following: The MDT is necessary to make a complete diagnosis of unresectable Stage III NSCLC. Prior to making treatment decisions, driver mutation and immune status should be assessed. Correct staging is essential for determining treatment. And, finally, operability should be determined by the MDT based on patient characteristics.
Dr Subramanian:
This brings us to the end of our first video, but be sure to look for other videos in the series. Thank you for watching.
Optimizing CRT in Unresectable Stage III NSCLC
Watch the lung cancer MDT at AdventHealth discuss diagnosis and staging for optimal NSCLC care.
Featuring: Dr Fortune Alabi, Pulmonologist; Dr Chung-Che (Jeff) Chang, Molecular Pathologist; Dr Charles (Wes) Hodge, Radiation Oncologist; Dr Tarek Mekhail, Medical Oncologist; Dr Mark Socinski, Medical Oncologist Brenda Rzeszutko, Nurse Navigator
Narrator:
Optimizing CRT in Unresectable Stage III NSCLC.
Narrator:
The views and opinions expressed in this video are those of the individual oncology specialists and do not represent the views or opinions of AstraZeneca. This video contains anecdotal information gathered from a discussion with oncology specialists based on their opinions/experiences. Recommendations are general and may vary with patients. At the time of this filming, the Healthcare Professionals featured were in the roles and at the institutions indicated.
Narrator:
The topics discussed in this video include the multidisciplinary team, determining radiation therapy, and preparing patients for CRT.
Dr Subramanian:
Hello, I’m Janakiraman Subramanian. I’m a medical oncologist. In this video, we’ll be talking about optimizing the use of chemoradiotherapy in unresectable Stage III non-small cell lung cancer. To help with that discussion, I’m joined by 2 thoracic oncology experts.
Dr Chun:
I’m Stephen Chun. I’m a radiation oncologist.
NN Roy:
Hi, and I’m Megan Roy. I’m an oncology nurse navigator.
Narrator:
Here is the first topic, the multidisciplinary team.
Dr Subramanian:
Once the multidisciplinary team has determined that the patient has been diagnosed and staged appropriately and meets the eligibility criteria for concurrent chemoradiation, it is the role of the medical oncologist and the radiation oncologist to develop the comprehensive plan.
Dr Subramanian:
The multidisciplinary setting is key to have those discussions rather than, as a medical oncologist, me independently making the decision. Having the input from you as a radiation oncologist, the nurse navigator who can give the background on this patient can really inform us on choosing the right treatment option for these patients.
Dr Chun:
Stage III disease is pretty heterogeneous, and each of the specialists on the team are critical for making the proper assessments that ensure appropriate treatment decisions.
Narrator:
Members of the MDT include medical oncologists, radiation oncologists, pulmonologists, pathologists, thoracic surgeons, and oncology nurses.
Dr Subramanian:
The nurse navigators, I think, are really at the center of a multidisciplinary team. They are the heart and the brain because they connect between all the other team members and communicate between them as well as with the patients. And so, they are absolutely indispensable, I think, for the MDT.
Dr Subramanian:
Now, Megan, as a nurse navigator, what is your role when these patients are newly diagnosed with non-small cell lung cancer, particularly Stage III unresectable disease?
NN Roy:
So, nurse navigation will help bring the patient’s point of view to that tumor board since they can’t be there, and let you know if they’re going to have transportation issues or are we going to have any other disparities of care, and be able to discuss what resources are going to be needed to help get that patient through that treatment.
Narrator:
Our next topic is determining radiation therapy.
Dr Subramanian:
As a medical oncologist, in some ways, the actual treatment planning is somewhat straightforward for me, particularly when giving it concurrent with the radiation, and that is primarily a platinum-based chemotherapy regimen is what we are choosing. But at the same time, we had to be careful in the sense whether the patient can tolerate that particular chemotherapy, and there are choices of chemotherapy regimens that we have to choose from, whether cisplatin or carboplatin-based regimens would be more appropriate is a decision that we have to make. Similarly, depending on the tumor histology, we may have to choose different types of chemotherapy treatment for those patients.
Dr Subramanian:
Now, from the radiation standpoint, how do you determine a patient is eligible for treatment?
Dr Chun:
So, I think when we look at the history of radiation for locally advanced non-small cell lung cancer, we used to think that only young patients with good performance status were candidates for chemoradiation. But with decades of research dating back to even the late 1990s, what we’ve seen is that even elderly patients with somewhat marginal performance status also benefit from chemoradiation. We should remember that the chemoradiation trials that are done today allow patients usually with a performance status up to 2, and that’s using the ECOG or Zubrod performance status system.
Dr Chun:
It’s also important to remember exactly what a performance status of 2 means. This isn’t just eyeballing a patient and kind of making a subjective judgment. It means someone able to care for oneself and up for more than 50% of waking hours. And so, again, I really urge people out there, don’t discriminate on the basis of something like age or disability. Really look at the definitions and be as objective as you can about what is the true performance status of this patient.
Dr Subramanian:
Now, Stephen, how do you prepare your patients particularly with radiation treatment that they have to be coming in every day and some of the later toxicities that you deal with?
Dr Chun:
When planning radiation therapy, whether it’s the National Comprehensive Cancer Network® (NCCN®) or the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®), the American Society of Radiation Oncology Guidelines, American Radium Society Appropriate Use Guidelines, whatever nationally validated guidelines you would be using, these are very important guidelines that serve as foundations to deliver safe and effective radiation plans for what we now recognize as often curable patients.
Dr Chun:
I am part of the process of planning radiation as a radiation oncologist. So I’m kind of the quarterback of the radiation planning team. This is a multi-step process that involves a number of different elements, including the radiation therapists, the radiation physicists, radiation nurses, and we develop plans based upon imaging, contouring both tumor and normal structures, and prescribing appropriate radiation doses for a specific patient.
Dr Chun:
Most patients these days are treated with advanced radiation techniques, specifically intensity-modulated radiotherapy, also known as IMRT. IMRT very carefully sculpts and molds to convex and concave shapes, whereas 3D conformal therapy, which is directed in straight lines at tumors, has less of an ability to shape to the often abnormal shapes of tumors. And this allows us with IMRT to treat tumors better, but also to spare normal tissues like the heart and the lungs from excess doses of radiation.
Dr Chun:
I almost exclusively use intensity-modulated radiotherapy for locally advanced lung cancer because of increasing evidence of the benefits of using intensity-modulated radiotherapy that reduces likelihood of pneumonitis or inflammation of the lungs. It also reduces cardiac exposure. And so, in the age of chemoradiation followed by appropriate therapies techniques like IMRT are of heightened importance in my opinion.
Narrator:
Our final topic is preparing patients for CRT.
Dr Subramanian:
Megan, how do you help prepare these patients for their upcoming concurrent chemoradiation treatment?
NN Roy:
I educate them about the type of lung cancer. I make sure they understand all their different treatment options. I let them know what to expect and how long and what is going to be required of them to make it through the whole treatment to keep them prepared as best as possible. I am constantly reinforcing the information they’re given, and I want to make sure they understand each step of the process.
NN Roy:
Once the patient agrees to getting chemoradiation, there’s a lot of different steps included. They have to get through their simulation and then they have to wait for that planning session to be done. So they’re calling me, “When am I going to hear? When am I going to hear?” So, it’s constantly re-educating and keeping in touch with the schedulers and making sure everything aligns right. And making sure they have my phone number because sometimes, depending on what institution you are in, it might be the only person that’s answering live and not getting a voicemail. So it’s really important for us to develop that relationship so they know they can call at any time.
NN Roy:
But another thing that’s really hard for patients is getting to the institution every day. It’s a long process. It’s six to seven weeks of daily radiation and once-a-week chemo most of the time. So it’s a lot for a patient who can’t communicate or needs to get a ride or lives two hours away and they might need lodging. So, getting a social worker involved early is really an important part so they can help start setting up those resources that are going to be needed. Getting that nutritionist involved early, and making sure that they know their calories and what they need to do to maintain their weight to get them through treatment is important also.
Dr Chun:
The radiation nurse, I agree, it is so important in helping me with the patient during and after treatment, including with the expected adverse events, particularly esophagitis that they might experience. But we also really rely on the nurse navigator to bridge the gaps in communication and help coordinate patients throughout this process.
Dr Chun:
What I think is really important is to try to put oneself in the mindset of a patient with locally advanced lung cancer. This is probably the most stressful situation they have ever been in in their entire lives. It is so important to explain things in simple ways.
Narrator:
In summary, in a Stage III NSCLC setting, effective multidisciplinary care can help ensure appropriate treatment decisions, which is particularly important given the heterogeneity of Stage III disease. It’s also important to be objective about performance status and which patients will be able to tolerate CRT. IMRT may further optimize treatment and reduce toxicities. Nurse navigators can help guide patients to complete their full treatment journey.
Dr Subramanian:
In closing, you can see that there is a lot of planning and preparation needed by all of us, along with our patients as well as their caregivers, to ensure that we can start concurrent chemoradiotherapy and ensure that it is optimally delivered for our patients. Be sure to look for other videos in the series. Thanks for watching.
Narrator:
There are additional resources on AZinearlylung.com that can help with patient management. These include the Patient Intake Form, the MDT Guide for Optimizing CRT, and the Nurse Guide for Week-by-Week AE Management during CRT.
Managing CRT-induced Adverse Events in Unresectable Stage III NSCLC
Watch the lung cancer MDT at AdventHealth discuss diagnosis and staging for optimal NSCLC care.
Featuring: Dr Fortune Alabi, Pulmonologist; Dr Chung-Che (Jeff) Chang, Molecular Pathologist; Dr Charles (Wes) Hodge, Radiation Oncologist; Dr Tarek Mekhail, Medical Oncologist; Dr Mark Socinski, Medical Oncologist Brenda Rzeszutko, Nurse Navigator
Narrator:
Managing CRT-induced Adverse Events in Unresectable Stage III NSCLC.
Narrator:
The views and opinions expressed in this video are those of the individual oncology specialists and do not represent the views or opinions of AstraZeneca. This video contains anecdotal information gathered from a discussion with oncology specialists based on their opinions/experiences. Recommendations are general and may vary with patients. At the time of this filming, the Healthcare Professionals featured were in the roles and at the institutions indicated.
Narrator:
Today, we will discuss how to manage toxicities as a multidisciplinary team, with a focus on the importance of early and frequent communication across the team, as well as the roles and responsibilities of everyone involved. We will also cover how proactive management of adverse events could help avoid treatment breaks.
Dr Subramanian:
Hello, I’m Janakiraman Subramanian. I’m a medical oncologist. Welcome to our video series on the changing landscape of unresectable Stage III non-small cell lung cancer. In this video, we’ll be talking about optimizing the use of concurrent chemo RT in unresectable Stage III non-small cell lung cancer. To help with that discussion, I’m joined by 2 thoracic oncology experts.
Dr Chun:
I’m Stephen Chun, I’m a radiation oncologist.
NN Roy:
Hi, I’m Megan Roy. I’m an oncology nurse navigator.
Narrator:
Managing toxicities as a multidisciplinary team: The importance of early and frequent communication
Dr Subramanian:
Stephen, in your opinion, how important is the collaboration within the multidisciplinary team so that we are managing these patients effectively, so that they complete the course of chemotherapy and radiation?
Dr Chun:
Collaboration with the full multidisciplinary team is of, in my opinion, utmost importance. The multidisciplinary team can be involved at times with input from the interventional pulmonologists, the nurse navigator with day-to-day management of patients as they undergo treatment. For me, it’s mostly a partnership with the medical oncologists and myself, to coordinate care during chemoradiation about what they’re going through regarding adverse events.
Dr Chun:
With chemoradiation, we want to make sure they get through the full treatment course without treatment breaks, and that requires frequent communication about how the patient’s doing. Because the patient comes in more frequently for radiation than for, let’s say, weekly chemotherapy, we oftentimes can observe changes that might be happening more quickly than the medical oncologists. If there’s an adverse event like esophagitis, or fatigue, or whatever adverse effect there is, we’re the first line of defense, but we immediately let medical oncology know. So they’re also on the lookout as to whether they need to do more workup in relation to side effects of chemotherapy.
Dr Subramanian:
So, Megan, how do you see yourself in making sure that the collaborative environment continues to work so that the patient is managed appropriately throughout their course of chemotherapy and radiation treatment?
NN Roy:
My role is to bridge those communication gaps between medical oncology, and radiation oncology, and the rest of the team that’s involved. I have reinforced the education of what adverse events they should look out for. So this way, they can report it as soon as they start feeling it. Because again, you know, if they say to me like, “Gosh, all of a sudden, I was short of breath walking out to my car,” it’s a red flag to let somebody know, to maybe they need some imaging, to make sure they don’t have pneumonitis or something.
NN Roy:
And during tumor boards, again, these multidisciplinary tumor boards are so important, so we got to make sure we have all the relevant information, so the specialists can make their decisions. I’ll report any issues the patient’s having to get them through treatment. For example, if the plan’s for them to come to the city every day, but they live right near one of our satellites, I might mention like, “Hey, they don’t have to drive. Is there any reason why they can’t go out to facility?” and help with those logistics. And also, keeping that patient voice up and present. A patient does have the final say of what treatment they want, so making sure that they are part of that treatment-decision process.
Dr Subramanian:
How do you keep them motivated, so that they can continue through with their treatment?
Dr Chun:
I really do think that morale is such an important part of what we do, whether it’s morale on a boat or morale during chemoradiation. But I always like to frame this in the broader perspective, that today, with chemoradiation and consolidative therapy, this truly is curative treatment.
Narrator:
Our next topic is roles and responsibilities across the team.
Dr Subramanian:
So what do you think is the role for the multidisciplinary team in helping you manage these adverse events for these patients?
Dr Chun:
I had a recent case of a patient, it was in the middle of chemoradiation, people didn’t know what was going on, because worsening respiratory status. I was pretty clear that this is probably not from radiation, because pneumonitis doesn’t happen during radiation. This patient also, because I talked with the pulmonologists, they thought that their COPD wasn’t bad enough to be causing their hypoxia, that they would be really surprised, looking at the pulmonary function tests, if the COPD was doing this. And sure enough, viral panel, it was influenza. So, the multidisciplinary team should always be looked to, especially when things might not be going as planned.
Dr Subramanian:
Agreed. You know, I’ve personally found it helpful, just like you said, to talk to my partners in the multidisciplinary team. Sometimes, it may be looking at an imaging study with my thoracic radiologist to help me understand what’s going on. Like you said, is it pneumonitis, or is it something else that’s happening for these patients? Could be an infection. And as you said, the timing of pneumonitis, knowing that is key, because radiation pneumonitis takes at least several weeks after radiation to develop.
Narrator:
The final topic is helping patients avoid treatment breaks through proactive management of AEs.
Dr Subramanian:
Stephen, how do you try to avoid interruptions to radiation treatments or dose reductions? The delays or dose reductions could be significantly detrimental for their ultimate outcomes, isn’t it?
Dr Chun:
Oh, that’s absolutely correct. And we know from many decades of research at this point that interruptions or dose reductions lead to less of an ability to control not just lung cancers, but all sorts of lung cancers. I break it down to patients: “We’re trying to kill this cancer, and we keep kicking it, and you want to keep kicking it while it’s down. If you have a break in radiation and allow that cancer to stand back up, you are risking not being able to kill that cancer.”
Dr Chun:
That, in a nutshell, that’s how I conceptualize it, you know, “Kick it while it’s down, and don’t let it get back up.” And this is also why I think involving social work isincredibly important. While we certainly have a lot of medical issues, medical logistics to address, there are also incredible social logistic issues. We can address all of the medical logistic issues as much as we want, but if the patient doesn’t have a car or transportation, it almost becomes a moot point.
Dr Chun:
Managing proactively is critical to maintaining that morale that we spoke about earlier. Having the patients have a good outlook, and that helps avoid breaks in radiation, which we know is detrimental to local control and survival. I actually tend to call in the supportive care team early in treatment, especially for a patient who’s running into trouble.
Dr Subramanian:
Megan, how do you kind of help to manage these adverse events for these patients?
NN Roy:
I don’t manage these toxicities directly, but I help bridge the gap to the teams that need to be managing them. So, if a radiation nurse notices that this patient’s looking dehydrated and especially fatigued, I might reach out to the medical oncology team and say, “Hey, do you think IV fluids might benefit this patient?” and help connect the dots both ways.
Dr Subramanian:
So, what tips do you have for the different adverse effects that the patients are dealing with when they’re going through chemotherapy and radiation treatments?
NN Roy:
We encourage the patients to stay hydrated by drinking their 8 glasses of water a day. We’re going to be monitoring their blood pressure and checking their labs, checking their skin turgor, to make sure that they’re not dehydrated and they don’t need IV fluids. For weight loss, the labs are also going to be checking their albumin. We’re going to be weighing them, to make sure that their weight’s staying stable. And again, the nutritionist is a crucial part of the team, and they can recommend some nutritional supplements, liquid if needed, and help them set their calorie goals and protein goals for their intake and decide whether it’s time to start thinking about a PEG tube.
Dr Chun:
The most common side effect that we see during radiation that gives us the most problems is the esophagitis. It causes pain, and because of that pain, patients don’t eat, it causes weight loss. So I usually start patients on an antacid, because if there is any acid reflux component of their esophagitis, we want to neutralize that stomach acid.
Dr Chun:
Other medications that I prescribe in addition to pain medicines, I always send in a prescription for a stool softener, because I know invariably that narcotics are going to cause constipation.
Dr Subramanian:
The whole idea, like you said, is to be proactive and have a combined multidisciplinary approach, so that we can prevent and control these adverse events as much as possible, so they don’t become too severe as soon as treatment’s either completed or stops treatment in the middle. We don’t want that, either. So we want our patients to be as healthy as possible after treatment, so that they can recover. And also, because treatment’s not over yet, there is consolidation part of the treatment—they should be in a good shape to go ahead and get those treatments.
Dr Chun:
Yeah, and I’ll typically talk to medical oncology after radiation is over to discuss when we should schedule the post-chemoradiation scan, to check for disease status, particularly checking if there’s progression, because that determines what the next steps of consolidative treatment are going to be. We’ll typically schedule the scan between 2 and 6 weeks after completing chemoradiation, although that can vary, depending on the medical oncologist and the situation of the patient.
Dr Subramanian:
And we need to keep in mind sometimes, when we do these scans early on, we may not necessarily see a great response to treatment. We may actually see some tumor changes that might suggest that there is progression. But we need to keep in mind that not every slight change in tumor size is progression of disease. Particularly, if you look at the RECIST criteria that maximal diameters of these tumors should be increased by more than 20%, really to say that it’s true progression, or they should have some new lesion that’s clearly cancer to call it progression.
Narrator:
In summary, manage adverse events along with the multidisciplinary team to help patients complete therapy. It’s important to keep patients motivated, and proactive management of adverse events may help patients avoid treatment breaks.
Dr Subramanian:
This concludes the videos in our series on the changing landscape of unresectable Stage III non-small cell lung cancer. Thanks for watching.
AEs=adverse events; CRT=chemoradiotherapy; IO=immuno-oncology; OS=overall survival; RT=radiation therapy.
References: 1. Chan C, Lang S, Rowbottom C, Guckenberger M, Faivre-Finn C; IASLC Advanced Radiation Technology Committee. Intensity-modulated radiotherapy for lung cancer: current status and future developments. J Thorac Oncol. 2014;9(11):1598-1608. 2. Chun SG, Hu C, Choy H, et al. Impact of intensity-modulated radiation therapy technique for locally advanced non–small-cell lung cancer: a secondary analysis of the NRG Oncology RTOG 0617 randomized clinical trial. J Clin Oncol. 2017;35(1):56-62. 3. Diwanji TP, Mohindra P, Vyfhuis M, et al. Advances in radiotherapy techniques and delivery for non-small cell lung cancer: benefits of intensity-modulated radiation therapy, proton therapy, and stereotactic body radiation therapy. Transl Lung Cancer Res. 2017;6(2):131-147. 4. Jegadeesh N, Liu Y, Gillespie T, et al. Evaluating intensity-modulated radiation therapy in locally advanced non–small-cell lung cancer: results from the National Cancer Data Base. Clin Lung Cancer. 2016;17(5):398-405. 5. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Non-Small Cell Lung Cancer V.7.2026. © National Comprehensive Cancer Network, Inc. 2026. All rights reserved. Accessed August 7, 2026. To view the most recent and complete version of the guideline, go online to NCCN.org. NCCN makes no warranties of any kind whatsoever regarding their content, use or application and disclaims any responsibility for their application or use in any way. 6. Baker S, Fairchild A. Radiation-induced esophagitis in lung cancer. Lung Cancer (Auckl). 2016;7:119-127. 7. Memorial Sloan Kettering Cancer Center. Radiation therapy to your head and neck: what you need to know about swallowing. Updated February 9, 2024. Accessed April 23, 2026. https://www.mskcc.org/cancer-care/patient-education/radiation-therapy-head-and-neck-swallowing 8. Santana-Davila R, Devisetty K, Szabo A, et al. Cisplatin and etoposide versus carboplatin and paclitaxel with concurrent radiotherapy for stage III non-small-cell lung cancer: an analysis of Veterans Health Administration data. J Clin Oncol. 2015;33(6):567-574. 9. Green MR, Rocha Lima CM, Sherman CA. Radiation and chemotherapy for patients with stage III non-small cell lung cancer. Semin Radiat Oncol. 2000;10(4):289-295.
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