ANNOUNCER: When doctors diagnose nonsmall cell lung cancer, they assign it a stage, often on a scale from one to four. This partly is based on how far the cancer has spread from the site of the original tumor, in a sequence that is generally well understood.
FRANK FOSSELLA, MD: Lung cancer, when it starts, originates somewhere within the lung and the way it progresses to other parts of the body, it typically will move into the lymph nodes first and so it may move first into the lymph nodes closest to where the original or what we say the primary tumor is. And then from there, spread to the lymph nodes and what we call the mediastinum, which is the central part of the chest between the two lungs. And then, from there, once it gets into those lymph nodes, then can spread into the blood, into other parts of the body, so then it can spread to the brain or bone or liver, pretty much anywhere in the body.
ANNOUNCER: Cancer in stage I and stage II disease has not spread from the lung with the original tumor to the opposite side of the chest, across the mediastinum. Generally, it can be treated by surgery. And this marks the difference between what doctors call early and advanced disease.
FRANK FOSSELLA, MD: I think a good working definition of early-stage versus advanced-stage nonsmall cell lung cancer would be whether the cancer is operable or not. And, usually, the cutoff there is going to be, stage I and II nonsmall cell lung cancer, we generally consider operable. Stage III and IV, for the most part, we consider inoperable and so they are treated primarily with chemotherapy and/or radiation therapy.
ANNOUNCER: The reason surgery is not usually an option in advanced disease is that surgery is only a local treatment.
RAMASWAMY GOVINDAN, MD: If you have a stage III lung cancer, the concern is, if the cancer has gone from the lung to the lymph glands, they could have gone through the bloodstream to other places. So going after the lung and the lymph glands by surgery by itself will not help because there are cells floating in the bloodstream.
ANNOUNCER: But there's a gray area within stage III disease when it comes to surgery.
FRANK FOSSELLA, MD: Now, there are certain subsets of stage III lung cancer that one would consider doing surgery for. These are specifically patients with stage IIIa lung cancer, and IIIa means that the cancer has spread to the lymph nodes on the same side of the mediastinum but has not spread to any other lymph node areas or to any other parts of the body.
ANNOUNCER: Even when surgery is called for with stage IIIa disease, it's not usually the first order of business.
RAMASWAMY GOVINDAN, MD: We tend not to operate on those patients right away. We tend to give them some kind of a treatment before surgery, what we call induction treatment.
FRANK FOSSELLA, MD: And the role of preoperative chemotherapy in these patients is to try to shrink the tumor down to make it easier for the surgeon to go in and remove the tumor. Then the other purpose of the chemotherapy is that if there is microscopic tumor elsewhere in the body that we're not picking up on the scans, that the chemotherapy would hopefully get rid of any microscopic cancer in the blood.
ANNOUNCER: A dual approach to treatment is also used in treating non-operable stage III cancer. In this case, it's chemotherapy plus radiation, an approach that is relatively new.
FRANK FOSSELLA, MD: And what we found in many of these studies that were done throughout the 1990s, is that there clearly is a survival advantage to treating stage III patients more aggressively with chemotherapy plus radiation therapy. And, although the survival rate is not as great as we would like it to be, we're looking at survival rates of about fifteen percent or so, compared with less than five percent with radiation alone.
ANNOUNCER: The chemotherapy agents currently used include cisplatin or carboplatin, combined with either paclitaxel, docetaxel, or etoposide. Different strategies for their use remain under study. Sometimes induction techniques are used, with chemotherapy before radiation.
When radiation is combined with chemotherapy, that's called concurrent treatment. Sometimes, additional chemotherapy follows concurrent treatment, a technique known as consolidation. These approaches have improved survival. One study of consolidation has been especially promising.
RAMASWAMY GOVINDAN, MD: Recently we have seen some data to suggest that patients with stage III nonsmall cell lung cancer, if they receive cisplatin, etoposide, radiation and subsequently Taxotere as a consolidation, the cure rates can be as high as 25 to 30 percent.
ANNOUNCER: Even with very advanced, stage IV disease, doctors say chemotherapy can offer some patients hope for longer survival.
RAMASWAMY GOVINDAN, MD: Fifteen years ago, we used to ask a question, "When a someone with stage IV lung cancer walks into your clinic, is it worth treating patients with stage IV nonsmall cell lung cancer?" Now we know, clearly, that chemotherapy not only prolongs life; it also improves the quality of life and this has been confirmed repeatedly.
ANNOUNCER: Some of the most promising research in the last five years involves what are called "targeted" therapies.
FRANK FOSSELLA, MD: The idea with the targeted therapy is that if we can identify a specific abnormality that is present only in the cancer cell and not in normal cells and then develop a drug against that particular abnormality, we can get death of the cancer cell and spare normal cells. And so there's been a lot of interest in developing so-called "targeted" therapy drugs.
ANNOUNCER: One of these targeted drugs, called erlotinib or Tarceva, has been approved for use when other treatments have failed. Other drugs, such as bevacizumab, or Avastin, have shown promise, but are still considered experimental.
Ultimately, doctors are hopeful that targeted therapies will effectively help tailor treatments to different subtypes of disease.
FRANK FOSSELLA, MD: And so, instead of treating all comers as nonsmall cell lung cancer, we'll really be able to tailor the therapy to the individual patient. Now, that's probably many years coming, but I think that's ultimately where we're headed.