2007

To help doctors give their patients the best possible care, the American Society of Clinical Oncology (ASCO) asks its medical experts to develop recommendations for specific areas of cancer care. ASCO and Cancer Care Ontario (CCO) together developed recommendations for treatment after surgery for non-small cell lung cancer. This patient guide is based on their recommendations.

As you read this guide, please keep in mind that every person treated for cancer is different. These recommendations are not meant to replace your judgment or that of your doctor. The final decisions you and your doctors make will be based on your individual circumstances.

Information in ASCO's patient education materials is not intended as medical advice or as a substitute for the treating doctor's own professional judgment; nor does it imply ASCO endorsement of any product, service, or company.

Non-small cell lung cancer (NSCLC) is the most common type of lung cancer. Adjuvant therapy is additional treatment given after surgery to reduce the risk that the cancer will come back. Adjuvant treatment may include chemotherapy (the use of drugs to kill cancer cells) and/or radiation therapy (the use of high energy x-rays to kill cancer cells). This patient guide explains whether chemotherapy and radiation therapy are recommended treatments after surgery to remove the lung cancer, depending on the stage of the cancer.

Staging is a way of describing the cancer, such as its size, and if or where the cancer has spread. Cancer may spread through the blood or through the lymphatic system. The lymphatic system is part of the immune system and drains fluid from body tissues through a series of tubes. Lymphatic fluid is filtered in small, bean-shaped organs called lymph nodes. When cancer cells travel in the lymphatic system, they become trapped in the lymph nodes. The treatment for stage I, II, and IIIA NSCLC includes surgery to remove the tumor and the surrounding lung tissue and lymph nodes.

The stage of NSCLC is described by a number, one through four (Roman numerals I-IV). A higher stage of cancer means that the risk that the cancer may come back is also higher.

• Stage I NSCLC means that the cancer has not spread to nearby lymph nodes. Stage IA means the primary tumor is relatively small. Stage IB means the primary tumor is relatively large, or is located in a place where it is more likely to spread. A stage I cancer can usually be removed by surgery.



• Stage II NSCLC describes a cancer that may have spread to nearby lymph nodes. Stage IIA means the primary tumor is relatively small. Stage IIB means the primary tumor is relatively large, or is located in a place where it is more likely to spread. In a stage II cancer, both the tumor and the affected lymph nodes can usually be removed by surgery.



• Stage III NSCLC may be difficult to remove with surgery. When the cancer has spread to lymph nodes in the center of the chest, on the same side as where the cancer started, it is known as stage IIIA. When the cancer spreads to lymph nodes on the opposite side of the chest, it is known as stage IIIB. In general, surgery is not used for any stage IIIB lung cancer.



• Stage IV NSCLC has spread through the bloodstream to areas of the body outside of the lung and is not treated with surgery.

This patient guide applies to stage I, II, and IIIA NSCLC. For information on stage IIIB and IV NSCLC, read the ASCO Patient Guide: Advanced Lung Cancer Treatment.

The ASCO and CCO recommendations for adjuvant treatment for stage I, II, and IIIA NSCLC include the following:

• Chemotherapy after surgery to remove the lung cancer is recommended for patients with stage IIA, IIB, and IIIA NSCLC because clinical trials have shown that it may help patients live longer.
  
  
• Chemotherapy after surgery is not recommended for patients with stage IA NSCLC because there is not enough evidence to show that chemotherapy helps these patients live longer, and because these patients tend to have a good chance of long-term survival with surgery alone. For the same reasons, chemotherapy for stage IB NSCLC is not recommended for every patient, but it may be appropriate in some situations. Talk with your doctor for more information.
  
  
• Radiation treatment after surgery is not recommended for patients with stage IA, IB, IIA, or IIB NSCLC because clinical trials have shown that it does not help patients live longer. Radiation therapy is not routinely recommended for all patients with stage IIIA NSCLC, but it may be helpful for some patients. Talk with your doctor for more information.

The ASCO/CCO recommendations are summarized in this table:

Table. Summary of Recommendations for Adjuvant Treatment of NSCLC

Chemotherapy is delivered as often as once per week for up to four months. The chemotherapy program should include the drug cisplatin (Platinol), plus one other drug. Your doctor can explain to you the names of the drugs and the treatment schedule.

Chemotherapy is given through the veins (intravenously, or IV), typically in your arm. The side effects of chemotherapy may include fatigue, nausea and/or vomiting, appetite loss, and irritation around the vein where the chemotherapy is injected. If you have small veins in your arms, the doctor may recommend that you have a venous access device implanted under your skin that allows the chemotherapy to be given directly into a larger vein in the neck or chest. Other, less common side effects include a decrease in the number of red blood cells (anemia), fever with a low number of white blood cells, hair loss, constipation, peripheral neuropathy (a numbness, or tingling of the fingertips and/or toes), kidney damage, and hearing loss. Often, these side effects go away after treatment, but damage to the nerves, kidneys, or hearing may be permanent. Because some patients (1%) who develop an infection while their white blood count is low from chemotherapy have died, you and your doctor should take all side effects of chemotherapy very seriously.

Radiation therapy is given as often as once a day, Monday to Friday, for up to six weeks. The side effects of radiation therapy may include difficulty breathing, a sore throat, difficulty eating or swallowing, and fatigue. These side effects usually go away after treatment.

Adjuvant treatment for early-stage NSCLC may lower the risk of the cancer coming back, but is also associated with potentially serious side effects. The chart above can help you learn whether adjuvant chemotherapy and/or radiation therapy is recommended for your stage of lung cancer. To learn more about adjuvant treatment for lung cancer, talk with your doctor about the type of cancer you have, your medical history, your overall health, and the risks and benefits of adjuvant treatment, including the potential side effects.

To learn more about adjuvant treatment for lung cancer, consider asking your doctor the following questions:

• What stage is the cancer?
  
  
• Would I benefit from adjuvant treatment?
  
  
• What are my treatment options?
  
  
• What treatment(s) do you recommend?
  
  
• What are the risks of this treatment?
  
  
• How could this treatment help me?
  
  
• What are the short-term and long-term side effects of this treatment? Are they preventable and/or treatable?
  
  
• How could this treatment affect my quality of life?
  
  
• Am I eligible for a clinical trial?
  
  
• Where can I find more information?
  
  

In addition, ASCO has created a Decision Aid Tool to help patients talk with their doctors about the risks and benefits of chemotherapy after surgery.

Read the entire clinical practice guideline published in the November 20, 2007 issue of the Journal of Clinical Oncology (JCO).

Cancer.Net Guide to Lung Cancer

Cancer.Net (www.cancer.net) is the comprehensive, oncologist-approved cancer information website from ASCO. Visit Cancer.Net to find guides on more than 120 types of cancer and cancer-related syndromes, clinical trials information, coping resources, information on managing side effects, medical illustrations, cancer information in Spanish, podcasts, the latest cancer news, and much more. For more information about ASCO's patient information resources, call toll free 888-651-3038.

Lung cancer resources

It's Time to Focus on Lung Cancer/Lungcancer.org
Toll Free: 877-646-5864
www.lungcancer.org

Lung Cancer Alliance
1747 Pennsylvania Ave. NW, 11th Fl.
Washington, DC  20006
Toll Free: 800-298-2436
Phone: 202-463-2080
www.lungcanceralliance.org

Lung Cancer Online
www.lungcanceronline.org

National Lung Cancer Partnership
222 N Midvale Blvd., Ste. 6
Madison, WI 53705
Phone: 608-233-7905
www.NationalLungCancerPartnership.org

General cancer and lung diseases resources

American Cancer Society
1599 Clifton Rd., NE
Atlanta, GA  30329-4251
Toll Free: 800-ACS-2345 (800-227-2345)
TTY: 866-288-4327
Phone: 404-320-3333
www.cancer.org

American Lung Association
61 Broadway, 6th Fl.
New York, NY  10006
Toll Free: 800-LUNG-USA (800-586-4872)
Phone: 212-315-8700
www.lungusa.org

CancerCare
275 Seventh Ave.
New York, NY  10001
Toll Free: 800-813-HOPE (800-813-4673)
Phone: 212-712-8400
www.cancercare.org

Cancer Care Ontario
620 University Ave.
Toronto, Ontario, Canada  M5G 2L7
Phone: 416-971-9800
www.cancercare.on.ca

National Cancer Institute
Public Inquiries Office
Building 31, Rm. 10A31
31 Center Dr., MSC 2580
Bethesda, MD  20892-2580
Toll Free: 800-4-CANCER (800-422-6237)
TTY: 800-332-8615
Phone: 301-435-3848
www.cancer.gov