Treating Stage 3A Lung Cancer: The Gray Zone

Fortunately, thanks to advancements in radiation, immunotherapy, surgical techniques, and targeted treatments there are now many options available to treat Stage 3A lung cancer. However, with many options and studies ongoing this can make deciding on the best approach difficult and there is controversy among oncologists on what is the best approach for treating people with stage 3A lung cancer. Some oncologists would recommend radiation therapy with chemotherapy and immunotherapy only while others would favor including surgery as part of the treatment pathway.  When discussing these controversies Dr. Friedberg says that in his opinion:

“it may be appropriate to give chemotherapy with or without radiation before surgery to people who are young and/or are otherwise healthy individuals. The goal is to shrink the tumor and kill all errant cancer cells before surgery and then remove the now smaller tumor.”

It is also entirely reasonable to treat patients with Stage 3A lung cancer without surgery. In this approach, patients will receive radiation therapy and chemotherapy given together followed by immunotherapy. This approach is more common in people with stage 3B/C lung cancer where surgery is much less feasible but is also a reasonable and common approach in patients with Stage 3A lung cancer. This approach may be recommended in multiple circumstances but the common scenarios where a non-operative approach is recommended would be in people who are not healthy enough to have surgery or when the surgeons do not think they will be able to successfully remove the entire tumor. A multidisciplinary approach where multiple specialists come together to discuss cases is extremely important for patients with stage 3A lung cancer.

The treatment for stage 3A lung cancer is growing even more complicated as multiple clinical trials are looking at the use of chemotherapy, immunotherapy, or both before surgery to help shrink the tumors and make them easier to remove.

Dr. Friedberg says “a controversial approach for treating 3A lung cancer is the removal of an entire lung, which obviously has a significant impact on a patient's quality of life." This extremely aggressive approach, where an entire lung is removed, is very rarely done and is only considered under very specific circumstances and patient factors. It would be much more common for definitive radiation therapy, chemotherapy, and immunotherapy to be given than to have a lung removed in the setting of stage 3A disease.

With regards to the use of surgery in patients with stage 3A disease, the NCCN panel notes that several clinical trials evaluated the role of surgery in this population and did not show an overall survival benefit with the use of surgery compared with radiation and chemotherapy. But the panel notes that it believes that these trials "did not sufficiently evaluate the nuances with the heterogeneity of N2 disease" and the likely benefit of surgery in some situations.

In cases where surgery is used, it is often followed by chemotherapy, immunotherapy, or radiation. The decision to give additional or adjuvant therapy after surgery is dependent on specific patient and pathological factors. These pathologic factors are determined after surgery when a pathologist examines the tissue under a microscope. In addition to chemotherapy, radiation therapy, and immunotherapy, targeted agents are also considered when appropriate or as part of a clinical trial.

If surgery, radiation, and chemotherapy are not options, certain immunotherapy treatments such as Keytruda (pembrolizumab) may be used alone as your first treatment. As discussed, the treatment for stage 3A lung cancer is rapidly evolving and the treatment approach has become more nuanced over time. Multiple clinical trials are looking to see if neoadjuvant (given before surgery) immunotherapy or chemoimmunotherapy may be effective in reducing the tumor size and burden and leading to increased chances of surgical cure. However, this is not the current standard of care.

RELATED: Immunotherapy Has Changed The Game For Lung Cancer

What you should know.

The treatment for stage 3A lung cancer is rapidly evolving. There is significant controversy and practice variation across the country on the best approach to treat this stage of lung cancer. It is recommended to get care at a center that treats many patients with stage 3A lung cancer and has a multidisciplinary cancer clinic. It is also important and reasonable to seek a second opinion if you have questions about your treatment plan or want to hear more from another institution.

Some people with stage 3A lung cancer will be treated with radiation therapy, chemotherapy, and immunotherapy without surgery whereas others may have chemotherapy or chemotherapy and radiation followed by surgery. Clinical trials are also great options and may allow access to new approaches for treating this disease.

As always, be your own advocate and discuss with your treating team about what approach is best for you.

Learn more about SurvivorNet’s rigorous medical review process.

Dr. Joseph Friedberg serves as a medical advisor to SurvivorNet.

Learn more about SurvivorNet's rigorous medical review process.

---