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The treatment goal for patients with stage III lung cancer is “CURED”!
The treatment goal for patients with stage III lung cancer is “CURED”! Lung cancer has always occupied the top spot in the oncology world, and it was not overtaken by breast cancer until last year, but the treatment is still not easy.
Patients with stage III non-small cell lung cancer have always been in a dilemma. It is not sooner or too late. The treatment is neither “everything” like in the early stage, nor is there a variety of targeted therapies that continue to emerge in the late stage. immunity therapy.
Of course, we have also seen that after all, patients in stage III have not reached the status of advanced distant metastasis, and there is still hope of cure after receiving standard treatment, especially the breakthrough in the 5-year survival rate after immune maintenance therapy. Immunotherapy is given to patients with stage III lung cancer. Bring surprises along the way.
01, Ⅲ stage non-small cell lung cancer patients, to achieve the goal of radical treatment
Stage I to III non-small cell lung cancer is called early or locally advanced lung cancer, and stage IV is called advanced stage. For these patients in stage I-III, the purpose of treatment is radical treatment. As for stage IV lung cancer, the main purpose is palliative treatment, which is a treatment model that prolongs the survival of patients.
So in terms of purpose, the expected end points for stage III and stage IV non-small cell lung cancer are different.
For many patients with stage IV non-small cell lung cancer, because there are very good treatment models, such as targeted therapy, immunotherapy and some combination therapies. A considerable part of patients with advanced lung cancer can survive for more than 5 years, which is the chronic trend of lung cancer.
For locally advanced non-small cell lung cancer, it is mainly divided into two categories, resectable and unresectable.
Stage I and II patients, the main treatment is surgery. For stage III lung cancer, those who cannot achieve the purpose of radical surgery at the first visit are called unresectable, and those patients who can achieve the purpose of radical resection are called resectable. All operations here refer to radical operations, including a complete lobectomy and systemic lymph node dissection.
Taking surgery as a watershed, for example, during the initial treatment, patients who are operable can be effectively downgraded through neoadjuvant treatment, and the tumor can be reduced to a certain extent within a certain period of time. Inoperable is transformed into operable. Neoadjuvant therapy includes neoadjuvant chemotherapy, neoadjuvant immunotherapy, or immune combined chemotherapy. Some patients can undergo an effective transformation to achieve a radical surgical resection.
Therefore, surgery is the first choice for patients with stage III lung cancer. If after all efforts, the patient still does not reach the indications of operable, it is necessary to consider inoperability. The most standard treatment plan for these patients is concurrent radiotherapy and chemotherapy. Radiation therapy, like surgical treatment, is a local treatment method, and both can achieve the purpose of effectively killing tumor cells or removing tumor cells.
02, Ⅲ stage lung cancer can also use targeted therapy and immunotherapy
From the perspective of TNM staging, T in stage III lung cancer can span from T1 to T4, and N can span across N1 to N3. It is a collection of very heterogeneous tumors, rather than a simple stage III. . Therefore, the overall treatment is more complicated, and it is also the staged treatment of tumors that are currently being explored.
If it is an operable patient, after the surgical treatment, there is a combination of gene mutations. At present, there is evidence that, especially the postoperative patients of N2 stage, can benefit from the postoperative targeted therapy. The targeted therapy here refers to Patients with EGFR mutations can use osimertinib after surgery. For patients with other mutations such as ALK and ROS1 mutations, there is currently no evidence to show whether adjuvant targeted therapy can be performed after surgery, so postoperative adjuvant chemotherapy is a necessary option.
For postoperative immune adjuvant therapy, there is currently no more evidence-based medicine basis, unless it is the part of patients who are transformed into operable after neoadjuvant downgrade, postoperative immune maintenance therapy may still be required. However, for patients who can be operated on initially, there is no need for postoperative adjuvant immunization after radical surgery, and there is currently no answer, nor is it a first-choice recommendation.
For inoperable patients, especially those patients who are still inoperable after neoadjuvant treatment, concurrent radiotherapy and chemotherapy must be a standard treatment plan. After concurrent radiotherapy and chemotherapy, PACIFIC’s research results pointed out that immune maintenance therapy can be carried out. Therefore, for patients who are negative for the mutant gene, they can also benefit from survival if they are given concurrent chemoradiotherapy and subsequent immune maintenance therapy.
03. These immune drugs are also suitable for stage III lung cancer
The indications for more and more immunosuppressive agents at the time of approval point out that for patients with advanced or inoperable locally advanced stages, immunosuppressant combined with chemotherapy can be considered. Therefore, for inoperable locally advanced patients, you may wish to consider referring to the treatment mode of advanced lung cancer. Chemotherapy combined with immunization is a good choice, but the prerequisite must first exclude that the patient may not be able to receive concurrent radical chemotherapy for the time being. .
In addition to the approved drug I (duvalizumab) in the PACIFIC study, there are currently approved drugs for non-squamous lung cancer, as well as sintilizumab and carrelizumab combined chemotherapy. There are K drugs and tislelizumab for squamous cell carcinoma, so for patients with stage III lung cancer, a suitable treatment mode can be selected from them.
04, PD-1 and PD-L1, the choice of drugs depends on the indication requirements
The immunosuppressive agents currently on the market are mainly divided into two categories, PD-1 and PD-L1. First of all, the binding site of the drug is different. In fact, PD-1 and PD-L1 are each other’s binding site, which is the binding site of the antibody and the receptor.
Secondly, when drugs are designed, they target different situations. Even the same type of PD-1 or PD-L1, the drug indications cannot be crossed. Different manufacturers design drugs with different binding sites and different antibody structures, which will also lead to differences in drug efficacy.
Therefore, in principle, although they are all the same type of PD-L1, they have to undergo rigorous research and verification, and the approved indications have more evidence, rather than pure drug exchange.
05. The 5-year survival rate of the PACIFIC study reached 42.9%, and immunotherapy made the tumor slower
For cancer patients, 5 years is a big threshold. Generally speaking, a survival time of more than 5 years can be regarded as a radical or self-healing treatment. In the PACIFIC study, for this part of patients undergoing concurrent radiotherapy and chemotherapy, the use of duvalizumab immune maintenance therapy in the later period can significantly improve the overall survival rate of the patients, and there is a long tail phenomenon. The long tailing effect of immune drugs shows that once the drugs are effective, they will be effective for a long time. Therefore, these patients can get long-term survival benefits from immunotherapy.
The 5-year OS rate in the PACIFIC study reached 42.9%. The publication of this data brings great confidence to the current clinical treatment. At the same time, if the current technology can more accurately identify which part of patients can benefit from immune maintenance therapy, then these patients may be able to truly achieve chronic disease.
06. Multidisciplinary diagnosis and treatment (MDT) is indispensable in the treatment of stage III lung cancer
MDT is particularly important in stage III lung cancer. Stage III lung cancer involves all aspects of treatment, including surgery, full participation in radiotherapy, subsequent immunotherapy, and full-course management during the treatment process. Corresponding departments are required. Including respiratory, cardiology, endocrinology, and gastroenterology, the participation of multiple departments can enrich the overall treatment of patients.
- First of all, for an inoperable patient, when it can be converted to surgery, it needs the full management and evaluation of MDT.
- Second, in the treatment of toxic and side effects, in the long-term survival process, there may be risks of recurrence and metastasis. For the occurrence of these conditions, full-scale intervention and management are indispensable. For patients with stage III non-small cell lung cancer, MDT can exert its greatest effect. At the same time, patients can also get the maximum survival benefit from the collaborative discussion of MDT.
07. Real patient case: immunotherapy allows patients to live long and well
There was a case that was very impressive, and it was also the first immunotherapy patient we came into contact with. The patient experienced rapid tumor progression after multi-line treatment. At that time, immune drugs had not yet entered mainland China, only in Hong Kong. The patient went to a hospital in Hong Kong to buy the medicine. After using it twice, he developed obvious interstitial pneumonia changes in one lung, but the patient had no obvious symptoms.
After a large dose of hormone therapy, the interstitial pneumonia on the lung has been completely relieved. But the amazing thing is that the rapid progress of the tumor is well controlled, and even the state of the tumor completely disappeared. At present, the patient’s survival time has been close to more than 4 years, and he is in a state of complete CR. This is also a very important reason why I am very confident in immunosuppressants. Immunotherapy can activate the body’s immune response and achieve the complete elimination of tumors, so that these effective patients can achieve long-term survival benefits.
08, Ⅲ stage lung cancer immunotherapy, these studies are worth looking forward to
For stage III lung cancer, the current research and development of neoadjuvant immunotherapy is in full swing, and many patients have obtained good survival benefits, and the pathology can also reach the state of PCR after being transformed into operable. At the same time, this is also the most direct evidence that immunotherapy can control and kill tumors well.
In addition, there are many developments in immunotherapy in lung cancer, including screening of immune checkpoints, and the duration of immunotherapy. Two years is currently a very important node. For some patients who still have survival benefits for more than two years, do they need to continue to be immune to maintain, or after the immune system is activated, it can show a good long tail effect Does it still need to be maintained for two years? Less than two years or more than two years. These are all questions that need to be answered in the future.
09. You need to pay attention to the diet and daily care before and after radiotherapy and chemotherapy
During radiotherapy, first, keep the skin dry, and the radiotherapy area should not touch water. Avoid the skin of the treatment area when bathing, sweating in summer and wiping sweat to avoid causing radioactive skin damage, or even local skin damage and infection.
Secondly, avoid sun exposure, as exposure will aggravate radioactive skin damage. Wear loose, pure cotton clothes. Do not wear clothes with strong friction to avoid local physical friction.
Third, eat lightly. The esophagus will receive a certain amount of scattered rays within the radiation area, and radiation esophagitis may occur. Patients should try their best to eat a light diet, not too spicy and irritating; the food should be cooler, not too hot, and reduce the irritation to the esophagus. In addition, some drugs can also be used to promote the repair of the mucosa, reduce the occurrence of complications and promote local recovery.
Also, be careful not to catch cold during radiotherapy. Radiotherapy itself can cause radioactive lung damage. During radiotherapy, lung infections caused by colds should be avoided. This period is more severe than usual colds and lung infections.
The current radiotherapy has entered the era of precision radiotherapy. It is required that during the entire radiotherapy period, the overall error should not exceed 5 mm, and the damage is also within a controllable range. I hope that patients do not need to worry too much, and at the same time take good protection.
(source:internet, reference only)