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Stages IIA and IIB NSCLC Treatment

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    Limitations of evidence (surgery):

    Conclusions about the efficacy of surgery for patients with local and locoregional NSCLC are limited by the small number of participants studied to date and potential methodological weaknesses of the trials.

    Neoadjuvant chemotherapy

    The role of chemotherapy prior to surgery was tested in clinical trials. The proposed benefits of preoperative chemotherapy include the following:

    • A reduction in tumor size that may facilitate surgical resection.
    • Early eradication of micrometastases.
    • Better tolerability.

    Preoperative chemotherapy may, however, delay potentially curative surgery.

    Evidence (neoadjuvant chemotherapy):

    1. The Cochrane Collaboration Review group reported a systematic review and meta-analysis of seven randomized controlled trials that included 988 patients and evaluated the addition of preoperative chemotherapy to surgery versus surgery alone. These trials evaluated patients with stages I, II, and IIIA NSCLC.[3]
      • Preoperative chemotherapy provided an absolute benefit in survival of 6% across all stages of disease, from 14% to 20% at 5 years (HR, 0.82; 95% CI, 0.69–0.97; P = .022).[3][Level of evidence: 1iiA]
      • This analysis was unable to address questions such as whether particular types of patients may benefit more or less from preoperative chemotherapy.
    2. In the largest trial reported to date, 519 patients were randomly assigned to receive either surgery alone or three cycles of platinum-based chemotherapy followed by surgery. Most patients (61%) had clinical stage I disease; 31% had stage II disease; and 7% had stage III disease.[4]
      • No survival advantage was seen.[4]
      • Postoperative complications were similar between groups, and no impairment of quality of life was observed.
      • There was no evidence of a benefit in terms of overall survival (OS) (HR, 1.02; 95% CI, 0.80–1.31; P = .86).
      • Updating the systematic review by addition of the present result suggests a 12% relative survival benefit with the addition of neoadjuvant (preoperative) chemotherapy (1,507 patients; HR, 0.88; 95% CI, 0.76–1.01; P = .07), equivalent to an absolute improvement in survival of 5% at 5 years.

    Adjuvant radiation therapy

    The value of postoperative (adjuvant) radiation therapy (PORT) has been evaluated.[5]

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