Current treatment paradigms for locally advanced non-small cell lung cancer

Locally advanced non-small cell lung cancer (NSCLC) is a multifaceted disease that is challenging to manage. The majority of patients can be appropriately treated with a combination of chemotherapy and radiation therapy; however, a subset of stage III patients who are considered surgical candidates may require a modification of this plan. For example, a trimodal approach using chemoradiation followed by surgery may be beneficial for fit patients with bulky mediastinal disease who are candidates for lobectomy, whereas patients with minimal mediastinal nodal involvement may receive only chemotherapy before surgical resection. No standard chemotherapy exists for this group of stage IIIA resectable patients. Phase II data from studies employing neoadjuvant cisplatin combinations suggest that these regimens are active and well tolerated. For patients with unresectable stage III NSCLC, concurrent chemoradiation is the standard of care at the present time for patients with good performance status, good pulmonary function tests, and an acceptable volume of normal lung receiving 20 Gy (V20). To manage distant micrometastasis further, induction and consolidation regimens are under investigation during which full-dose chemotherapy is administered either before (as induction) or after (as consolidation) concurrent chemoradiotherapy. To date, consolidation docetaxel after concurrent etoposide, cisplatin and thoracic radiation has shown encouraging survival results in a large Southwest Oncology Group phase II trial. This article will review the current treatment strategies for stage III NSCLC.