Therapeutic options for regionally advanced non-small cell lung cancer

The optimal treatment for regionally advanced non-small cell lung cancer (NSCLC, Stage IIIa/IIIb) remains unknown. Proposed approaches include surgery, radiotherapy, chemotherapy, and combinations of these. No treatment modality, however, has ever shown other than modest or minimal beneficial effects. When differences between new and old treatments appear trivial, as in the management of the locally advanced NSCLC, controlled studies are necessary to select the best approach. This review is based on a systematic overview of data from randomized trials comparing different treatment modalities. The following six points emerged from the cited literature. (1) It is sufficiently proved that chemotherapy alone prolongs survival in patients with both locally advanced and metastatic disease. (2) Although it is probably true that radiation therapy is better than no active treatment, this idea is supported by very limited evidence. (3) Although it is probably also true that radiotherapy alone is not worse than chemotherapy alone, this is another insufficiently proved issue. (4) The possible superiority of chemo-radiotherapy to chemotherapy alone or to supportive care is also poorly documented. (5) There is abundant evidence that chemo-radiotherapy is better than radiotherapy alone (however, this information may be unhelpful if point 2, or 3 remains unclarified). (6) Although neoadjuvant treatments have improved resectability and may ensure overall better results, the surgical cure, either alone or in combination with chemotherapy or chemo-radiotherapy, is another unproved option. Based on the above six points, it was concluded that new randomized studies are urgently needed to confirm the possible superiority of chemo-radiotherapy to chemotherapy. Only after such a validation, will the many ongoing trials, designed to prove the possible superiority of local surgical control to the more traditional approaches based on thoracic irradiation, have a practical sense.