Narrative review of the management of stage IIIA non-small cell lung cancer: does different management equal different quality of life?

Abstract

Lung cancer remains the leading cause of cancer related deaths worldwide. A state of equipoise exists due to the expansive evidence base and increasing number of randomised trials testing promising therapeutic drugs and combined treatments. Treatment success should be determined through measuring both efficacy and the maintenance of quality of life (QoL). QoL in lung cancer patients is reported as being lower than in other malignancies, with independence and the ability to perform normal activities ranking as the most important issues. Management of stage IIIa non-small cell lung cancer (NSCLC) remains contentious due to its heterogeneity. For resectable disease, QoL and survival remain higher in those receiving lung parenchyma sparing surgery, such as lobectomy/bilobectomy, compared with pneumonectomy. The addition of neoadjuvant or adjuvant chemotherapy further improves outcomes and has become the standard of care. Whilst some research on QoL in patients receiving chemotherapy has consistently reported a negative correlation between the number of treatment cycles and QoL, other studies have found that chemotherapy may show positive effects on specific QoL domains such as functional activity and pain. Comparatively chemoradiotherapy (CRT) is more effective at reducing tumour/nodal size in resectable disease with no subjective decrease in QoL with the addition of radiotherapy (RT) (despite its increased toxicity) highlighting its potential use as an adjunct. In non-resectable stage IIIa NSCLC, definitive CRT remains the mainstay of treatment. Its efficacy has been well established when compared with RT or supportive care alone. Patients report improved QoL when receiving CRT compared with chemotherapy. Assessing possible effects on health-related QoL remains important when planning multi-modality cancer therapy. This review discusses the differing/compounding impact different treatment strategies for stage IIIa NSCLC have upon patient’s QoL and reported outcomes.