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Case History

Image not available. You are asked to see a 54-year-old woman with advanced non-small cell lung cancer (NSCLC), staged as T4 N2 M1 (lung metastases). Taking a careful history, you decide her performance status is 1.

What is the predicted survival for such patients?

What therapeutic options will you discuss with her?

If you and she reach a decision to try chemotherapy, what regimen(s) could you choose and on what evidence would this choice be based?

There is a good partial response on the end-of treatment scan but 3 months later a computed tomography (CT) scan shows asymptomatic progression in the primary lesion (T4). Her performance status remains very good.

How will you approach the management now?

Background

What is the predicted survival for such patients?

Image not available. With rare exceptions, patients with advanced NSCLC die from their disease. The overall median survival ranges from less than 6 months for patients with poor performance status to 2 years for fit patients with stage IIIB disease. The proportion of patients who are alive 1 year after diagnosis has increased slightly over the past decade with about a third of patients with stage IIIB or IV disease being alive at 1 year and 10–21% alive 2 years after diagnosis. The most important factor predicting survival is the performance status. Patients with advanced NSCLC who are compromised by their disease have much poorer survival compared with those less compromised. This stark contrast was first documented by Finkelstein et al. in a landmark analysis of 893 patients with stage IV NSCLC. In that study, the 1-year survival rate was 36% for patients with performance status 0, 16% for performance status 1, and 9% for performance status 2 (P Image not available.0.001). In the era of modern chemotherapy, performance status is still predictive of survival, as well as of toxicity of treatment.1,2

What therapeutic options will you discuss with her?

The goal of treatment of all patients with advanced NSCLC is to improve symptoms and delay disease progression while maintaining the quality of life (Figure 34.1). A meta-analysis and at least 1 randomized trial have shown a modest but marked survival advantage in favour of best supportive care (BSC) with chemotherapy compared with BSC alone in patients with good performance status.3,4 An improvement in the median survival time of 6–8 weeks is expected for those advanced NSCLC patients who are receiving platinum-based chemotherapy, translating to a 10% improvement in the 1-year survival rate. Therefore, a 54-year-old woman with performance status 1 should be offered combination chemotherapy with a clear explanation of the benefits and the associated risks. Equally important is good supportive care, addressing symptoms such as superior vena cava obstruction, haemoptysis, upper airway obstruction and bone pain. As the objective response rate to chemotherapy is less than 50%, symptoms such as these are usually ...

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