What is the diagnosis and treatment for lung carcinoma (lung cancer)?

From the Guidelines

Lung cancer treatment should prioritize a multidisciplinary approach, with surgery, chemotherapy, radiation therapy, targeted therapy, and immunotherapy considered based on the cancer type, stage, and patient's overall health, as recommended by the most recent guidelines 1.

Key Considerations

• Early detection is crucial for better outcomes, typically through chest X-rays, CT scans, and biopsy.
• Treatment depends on the cancer type, stage, and patient's overall health.
• A multidisciplinary team, including representatives from pulmonary medicine, thoracic surgery, medical oncology, radiation oncology, radiology, and pathology, should be involved in the diagnostic and treatment process 1.
• For patients with stage I and II non-small cell lung cancer (NSCLC), surgical resection is recommended, with adjuvant and/or neoadjuvant chemotherapy considered in certain cases 1.
• Targeted therapy, such as erlotinib or crizotinib, and immunotherapy, like pembrolizumab or nivolumab, may be considered for patients with specific genetic alterations or tumor characteristics 1.

Diagnosis and Staging

• Pathological diagnosis should be made according to the World Health Organization (WHO) classification, with the International Association for the Study of Lung Cancer (IASLC) classification of adenocarcinoma providing additional guidance 1.
• Staging should be performed using a combination of imaging studies, including CT scans and PET scans, and biopsy results.

Treatment Options

• Surgery: surgical resection is the primary treatment for early-stage NSCLC, with lobectomy or pneumonectomy considered based on the tumor location and size.
• Chemotherapy: chemotherapy may be considered as adjuvant or neoadjuvant therapy, with drugs like cisplatin, carboplatin, paclitaxel, or gemcitabine used.
• Radiation therapy: radiation therapy may be considered for patients with inoperable tumors or as adjuvant therapy after surgery.
• Targeted therapy: targeted therapy, such as erlotinib or crizotinib, may be considered for patients with specific genetic alterations, such as EGFR mutations.
• Immunotherapy: immunotherapy, like pembrolizumab or nivolumab, may be considered for patients with advanced NSCLC and high PD-L1 expression.

From the FDA Drug Label

INDICATIONS AND USAGE KEYTRUDA is a programmed death receptor-1 (PD-1)-blocking antibody indicated: Non-Small Cell Lung Cancer (NSCLC) in combination with pemetrexed and platinum chemotherapy, as first-line treatment of patients with metastatic nonsquamous NSCLC, with no EGFR or ALK genomic tumor aberrations. (1.2) in combination with carboplatin and either paclitaxel or paclitaxel protein-bound, as first-line treatment of patients with metastatic squamous NSCLC. (1. 2) as a single agent for the first-line treatment of patients with NSCLC expressing PD-L1 [Tumor Proportion Score (TPS) ≥1%] as determined by an FDA-approved test, with no EGFR or ALK genomic tumor aberrations, and is: Stage III where patients are not candidates for surgical resection or definitive chemoradiation, or metastatic. (1.2. 1) as a single agent for the treatment of patients with metastatic NSCLC whose tumors express PD-L1 (TPS ≥1%) as determined by an FDA-approved test, with disease progression on or after platinum-containing chemotherapy. Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving KEYTRUDA. (1.2. 1) for the treatment of patients with resectable (tumors ≥4 cm or node positive) NSCLC in combination with platinum-containing chemotherapy as neoadjuvant treatment, and then continued as a single agent as adjuvant treatment after surgery. (1. 2) as a single agent, for adjuvant treatment following resection and platinum-based chemotherapy for adult patients with Stage IB (T2a ≥4 cm), II, or IIIA NSCLC. (1.2)

Lung Cancer Treatment Options

• Pembrolizumab (KEYTRUDA): is indicated for the treatment of patients with non-small cell lung cancer (NSCLC) in various settings, including first-line treatment, adjuvant treatment, and treatment of metastatic disease.
• Nivolumab (OPDIVO): is also indicated for the treatment of patients with NSCLC, including resectable NSCLC, metastatic NSCLC, and NSCLC with PD-L1 expression. Key Considerations
• PD-L1 expression is an important factor in determining treatment eligibility for both pembrolizumab and nivolumab.
• Patients with EGFR or ALK genomic tumor aberrations should have disease progression on FDA-approved therapy for these aberrations prior to receiving pembrolizumab or nivolumab. 2 3

From the Research

Overview of Lung Cancer Treatment

• Lung cancer treatment varies depending on the stage and type of cancer, with options including surgery, radiation therapy, chemotherapy, and immunotherapy 4, 5, 6, 7, 8
• Non-small cell lung cancer (NSCLC) is the most common type of lung cancer, and treatment options include surgical resection, radiation therapy, and chemotherapy 4, 5

Treatment Options for Non-Small Cell Lung Cancer

• Surgical resection is reserved for operable patients with early-stage NSCLC, while high-dose target radiation-stereotactic body radiation therapy (SBRT) is reserved for patients whose comorbidities prohibit them from a major surgical procedure 4
• Chemoradiation therapy with adjuvant durvalumab is used for patients with unresectable disease 4
• The combination of SBRT and systemic therapy is used for patients with limited metastatic disease 4

Role of Radiation Therapy in Lung Cancer Treatment

• Radiation therapy has a well-established role in the treatment of NSCLC and has been shown to be immunostimulatory, with the potential to enhance the efficacy of immunotherapy 7, 8
• The addition of radiation therapy to immunotherapy has been shown to improve the abscopal response rate, progression-free survival, and overall survival in metastatic NSCLC patients 7

Comparison of Surgery and Radiation Therapy for Early-Stage NSCLC

• Surgery is currently the standard of care for patients with operable stage I NSCLC, but promising outcomes with SBRT in patients with inoperable disease has led to interest in directly comparing SBRT and surgery in operable patients 5
• Retrospective and prospective analyses of SBRT in early-stage NSCLC have shown promising results, but randomized trials are needed to fully compare the two approaches 5

Immunotherapy and Radiation Therapy Combination

• The combination of immunotherapy and radiation therapy has shown promise in enhancing therapeutic benefit for NSCLC patients 7, 8
• Factors such as low programmed cell death protein ligand 1 (PD-L1) status, tumor mutational burden (TMB), and patient's immune function may be associated with a proportionally greater benefit to additional radiation therapy 7