Research & Education

Conversation with Dr. Francoise Mornex and Dr. Punnarerk Thongcharoen in Conjunction with 2016 Asia Pacific Lung Cancer Conference (APLCC)

May 13, 2016

APLCC 2016
 
Contact: Jeff Wolf                                                                                                 Becky Bunn, MSc                                          
IASLC Director of Communications                                                                  IASLC Project Specialist                    
Jeff.Wolf@IASLC.org | 720-325-2952                                                             Becky.Bunn@IASLC.org | 720-325-2946       

 

Conversation with Dr. Francoise Mornex and Dr. Punnarerk Thongcharoen in Conjunction with 2016 Asia Pacific Lung Cancer Conference (APLCC)
Dealing with stage IIIA N2 Non-Small Cell Lung Cancer (NSCLC)

Stage IIIA NSCLC is a single cancer mass that is not invading any adjacent organs, but has spread to nearby lymph nodes in the chest. Stage IIIA cancers are further subdivided into N1 and N2 subgroups. N1 cancers involve lymph nodes farther away from the heart and are easier to remove with surgery. N2 cancers involve lymph nodes that may be difficult to remove with surgery because they are located in the part of the chest cavity that is between the lungs and contains the heart.

Stage III NSCLC Background
The treatment of locally advanced non-small cell lung cancer (NSCLC) is becoming a significant challenge because of a growing proportion of patients with unresectable (cannot be operated upon) stage III disease. Despite a multimodality approach consisting of concurrent chemo-radiotherapy, the prognosis remains poor.

“Before starting treatment, the stage IIIA or IIIB status of the patient needs to be confirmed. They should have had their CT scan, brain MRI and PET scan done and, additionally, if possible, their N2 status must have been proven either by mediastinoscopy or by endotracheal or endo-esophagus endoscopy. This ensures that they do not have metastasis, their N2 status is known and the size of the tumor is in stage IIIA or IIIB,” said Dr. Francoise Mornex, Professor of Oncology at University Claude Bernard in Lyon, France. She is also the Chairman of the Radiation Oncology Department in Lyon, Centre Hospitalier Lyon Sud, and member of the Board of Directors of IASLC and on the+ APLCC 2016 Committee.

Current survival rate: There are different survival rates for different subcategories of Stage IIIA N2 NSCLC patients. For stage 3A for inoperable patients: 36 percent of the patients are still alive at 5 years. For stage 3B this figure is 26 percent and for stage 3C (the new stage which will be introduced now) 5-year survival is 13 percent. So survival rate is between 13 percent and 36 percent at 5 years, depending upon the size of the tumor and the status of the mediastinal nodes.

Investigative Staging for Mediastinal Node is Key
Dr. Punnarerk Thongcharoen is a senior thoracic surgeon at Siriraj Hospital, Thailand’s oldest and largest hospital. He is also part of the Faculty of Medicine, Mahidol University and a member of the APLCC 2016 Local Organizing Committee agrees

He agrees with Dr. Mornex, stating: “Just like other cancers, if lung cancer is diagnosed when the disease is in an early stage then there are more chances of curing it with surgery. If it is an advanced case of lung cancer then chances of a cure are less. Hence the first thing is to identify whether N2 lymph nodes are involved or not – only then we should progress ahead and manage patients properly. If it is N2 disease then we need to further classify whether it is bulky N2 disease (advanced stage) or non-bulky N2 disease. For bulky N2 lung cancer, chemotherapy and radiation therapy might be better options. For non-bulky lung cancer disease, surgery may still have a role. Usually we start with chemotherapy and radiotherapy first and then reassess if we are able to resect the tumor.”

“Some physicians and surgeons are still relying on non-invasive staging approaches like a CT scan or PET scan. We should e7ncourage treating doctors to get the status confirmed whether it is N2 disease or not. So the key is to do investigative staging for mediastinal nodes. We also need to train more doctors to be able to do these investigative staging procedures well and encourage all healthcare professionals to stay updated with the latest guidelines in lung cancer management,” he said.

“As of now, with the current treatment for this stage of lung cancer, a therapeutic plateau has been reached,” Dr. Mornex said. “But, there is hope that progress will come from the metabolic imaging - the use of PET scanning before and during concurrent chemo-radiation. This will help to evaluate the response of the tumor to this combined treatment and also help in increasing the dose of radiation in specific resistant areas of the tumor.”

Do Not Lose Hope if NSCLC is Unresectable
The research focus of Dr. Mornex is specifically focused on those stage IIIA N2 NSCLC patients who are unresectable because either their tumor is too big to be surgically removed or they are inoperable because of their local conditions due to comorbidities. Most of these are fragile and old patients. The median age of these patients is 71 years and they suffer from a lot of comorbidities because of their age, and because many are smokers.

Dr. Mornex explained, “The current treatment regimen for these patients is concurrent chemo-radiation. But unfortunately less than 50 percent of them are able to tolerate this regimen because of their advanced age and comorbidities. For patients who cannot be treated with concurrent chemo-radiation, mostly induction chemotherapy, followed by a full dose of radiation, is done. This is called a sequential treatment – chemotherapy followed by radiation.”

“In those patients who can be put on concurrent chemo-radiation, there is a choice of several drugs. Most of the time we use a doublet - meaning two agents of chemotherapy – one of which usually is cisplatin, if the patient is less than 70-75 years old, and this can be joined with another drug like Vinorelbine, VP16, gemcitabine, or taxol. In cases where the patients are fragile or 70-75 years old or more, we will use carboplatin instead of cisplatin. So, if the patient’s condition permits, we mostly use two agents of chemotherapy – one of them being a platinum agent. Regarding radiation, there is still a question mark on what radiation dose is appropriate to be delivered. But, based on the results of a large randomized controlled study called RTOG 0617 that were presented in 2015, a lower dose of standard radiation of 60 Gray (Gy) gave a better outcome in terms of median survival when compared to the high dose radiation. So, the current recommendations are to combine two agents of chemotherapy and 60 Gy of radiation,” Dr. Mornex said.

What Radiation Technique Should be Used?
“There is a choice of using either the technique of 3D conformal therapy or Intensity Modulated Radiation Therapy (IMRT),” Dr. Mornex said. “In the RTOG 0617 trial, 47 percent of the patients received IMRT technique that gave better results, even though the tumors on which it was used were larger compared with those on whom conformal 3D therapy was used. Moreover, IMRT has shown to also better protect the normal organs, especially the heart. So, for patients of stage IIIA N2 of NSCLC cancer we should use two agents of chemotherapy, 60 Gy of radiation, and, if possible, IMRT technique for radiotherapy.”

The Way Forward
The question for this stage of lung cancer is to know how to integrate correct systemic adjuvants, and more specifically, targeted therapy and immunotherapy.

“We have some trials combining targeted agents and concurrent chemo-radiation, or trials introducing targeted adjuvants before concurrent chemo-radiation or after chemo-radiation. We have tried GKI, Erlotinib, Gefitinib, and Cetuximab. But so far, for tyrosine kinase inhibitor (TKI) therapy, none of these agents, when used with concurrent chemo-radiation, have helped in improving the results,” Dr. Mornex said.

“There are several ongoing trials with new agents that might hopefully improve the results. Some of these trials are dedicated to Asia, because Asian patients do not have the same mutations as European or American patients. It will be extremely important to compare the results of the same trial designed in Asia with those in other parts of the world, because it is important to have responses of different tumors and a precise tolerance profile to these new agents, especially when combined with radiation,” Dr. Mornex said.

Changing Scenario
Dr. Mornex added, “Now we are observing more non-smoking and young patients with this type of cancer, who are younger and have never smoked – something I did not see 20 years ago in my clinical practice. Obviously, there are some changes in the chromosomes, and we are not sure about the factors which are affecting the genes in the mutations of our patients. It has not yet been possible to show whether or not this cancer in young patients or in non-smokers will be different in terms of outcomes for the same cancer in smoking patients. The good news is that for these patients we can identify if they have some known mutations or not, and if they have this mutation we can propose to them very specific treatments with good outcomes. So, we will be able to personalize the treatment that we are offering to our patients, and by this way also we should be able to improve survival rates. One of the big questions will be to know how to combine the new agents (which are driven by the mutations of the patients) with chemo-radiation to improve results without increasing toxicity. I think with the new agents and the combination of the new agents and the recent radiotherapy treatments we should be able to dramatically improve the results for this disease in the near future. Targeted therapies and immunotherapy are likely to improve the management of locally advanced NSCLC in the future.”

 

For more information on IASLC Asia Pacific Lung Cancer Conference, please visit:

Website: www.aplcc2016.com | Twitter: @APLCC2016 | Facebook.com/APLCC2016

 

About the IASLC
The International Association for the Study of Lung Cancer (IASLC) is the only global organization dedicated solely to the study of lung cancer. Founded in 1974, the association's membership includes more than 5,000 lung cancer specialists in over 100 countries. Visit www.iaslc.org for more information.

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(This article was written jointly by Shobha Shukla and Bobby Ramakant of CNS (Citizen News Service) and edited by IASLC. CNS is a media partner of APLCC 2016. Follow CNS on www.citizen-news.org Twitter: @CNS_Health, Facebook.com/CNS.page and YouTube.com/c/CitizenNewsOrgCNS)