Introduction
Lung cancer is divided into two different types. The most common type is "non-small cell". lung
cancer (about 85% of all lung cancers). The remaining 15% is called small cell lung cancer. Treatment approaches and the course of the disease differ between these two types of lung cancer. In this article, the approach to diagnosis and treatment of non-small cell lung cancer (NSCLC)
is reviewed.
NSCLC is one of the most common cancers. It is estimated that there are 59 patients for men and 10 patients for women per hundred thousand population in our country. Accordingly, 27,000 new patients are expected every year
. When divided into subgroups, squamous cell type, adenocarcinoma type and large cell type are the most common types.
How is it diagnosed?
When the diagnosis is suspected, usually chest radiography, computerized It is evaluated by tomography or PET
tomography. However, for a definitive diagnosis, it must be confirmed by biopsy
. Bronchoscopy is usually performed for this purpose. When determining the stage of the disease
the standard and first choice method is PET-CT. Endobronchial ultrasonography (EBUS) is a method that has become increasingly important in recent years, allowing visualization of lesions and lymph nodes adjacent to the airway in areas that fiberoptic bronchoscope cannot see. EBUS
guided transbronchial needle aspiration is frequently used for mediastinal staging
.
Treatment in Advanced Stage Non-Small Cell Lung Cancer
p>Approximately half of the patients are in advanced stage (stage IIIB or stage IV) at the time of diagnosis. In the early stages
(stage I-II) surgery is performed as standard, in locally advanced stages (stage IIIA and IIIB) there may be cases suitable for surgery
Although there may be cases suitable for surgery, simultaneous chemoradiotherapy is generally preferred.
>Chemotherapy is the standard treatment approach in the treatment of advanced non-small cell lung cancer
.
Patient and tumor characteristics should be taken into consideration before making a chemotherapy decision. The age of the patient and the presence of other accompanying diseases such as diabetes and heart problems It affects the treatment plan
. The benefit of chemotherapy is controversial in older patients and debilitated patients with poor performance status. Among the tumor characteristics, factors such as the subtype of the cancer (adeno vs squamous cell) and the presence of genetic mutations are taken into account.
If there is no urgent need for treatment in non-squamous cell lung cancer types, molecular
Genetic tests should be waited for. Tumor histology and molecular markers, including epidermal growth factor
receptor (EGFR) mutation status and EML4/ALK translocation, are important factors to consider in treatment selection. EGFR mutation
is seen in approximately 15% of patients, ALK rearrangement in 5% of patients, and oral drugs called target-directed smart molecules are at the forefront in the treatment of these types.
Advanced stage. In the first-line treatment of NSCLC, EGFR
targeted agents such as erlotinib, gefitinib, and afatinib play an important role in EGFR mutation-positive patients, and drugs such as crizotinib play an important role in patients with the EML4-ALK
fusion gene. A combination of chemotherapy drugs is applied to patients who are not suitable for these treatments. Today, guidelines strongly recommend deciding on a first-line cytotoxic chemotherapy
regimen based on histology, in addition to age, stage, and
performance status.
The first indicator of the benefit of chemotherapy in the treatment of metastatic NSCLC. It came from a meta-analysis published in 1995
that included 11 studies and 1190 patients. This analysis showed a survival advantage
in patients treated with cisplatin-based agents compared to supportive
treatment alone. Subsequently updated data from this analysis, which included 2714 patients and 16 studies, confirmed the previously identified survival benefit. Among the chemotherapy types given, none has been shown to be superior to the other. Individualization of treatment by looking at other molecular factors such as ERCC1, RRM1, TS, BRCA1 has no superiority over the standard approach.
American Society of Clinical Oncology (ASCO) determines disease progression for metastatic NSCLC
< First-line chemotherapy should be discontinued in case of p>or in patients with stable disease following 4 cycles of chemotherapy but who do not respond to treatment. recommends. Guidelinesdo not recommend giving two-drug cytotoxic chemotherapy regimens for more than 6 cycles
. In patients with stable disease and response to treatment after four cycles of treatment, single-agent maintenance therapy (in patients not selected for erlotinib or docetaxel, pemetrexed for histology other than squamous cell type) should be considered. It has been reported that adding pemetrexed to platinum in non-squamous cell types is superior to other combinations.
Treatment guidelines state that platinum is docetaxel,
paclitaxel, in patients with squamous cell histology. Its combination with gemcitabine or vinorelbine and platinum + pemetrexed treatment is recommended for non-squamous cell (adeno
or large cell) types.
Immunological treatments work by strengthening the patient's immune system.
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