The first 60 days: Unresectable stage III non-small-cell lung cancer
Stage III lung cancer that cannot be removed is treated with chemotherapy and radiotherapy together, aiming at cure. A year of the immunotherapy antibody durvalumab afterwards raised five-year survival from a third to over 40 percent, and for EGFR-mutated tumours osimertinib after chemoradiation holds the disease for years. Below, week by week, is what OnCo's record of Unresectable stage III non-small-cell lung cancer says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
Ask which of these were tested and what the results were; see the report reader for what each value means.
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- Medical oncologistNamed in the standard of care for: Unresectable stage III, fit, no EGFR mutation, Unresectable stage III, EGFR-mutated, Unfit for concurrent treatment.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Unresectable stage III, fit, no EGFR mutation, Unresectable stage III, EGFR-mutated, Unfit for concurrent treatment, Toxicity.
- Transplant and cell therapy teamNamed in the standard of care for: Unresectable stage III, fit, no EGFR mutation.
- Palliative and supportive care teamNamed in the standard of care for: Toxicity.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
Concurrent platinum-based chemoradiation to 60 Gy with intensity-modulated radiotherapy, then durvalumab for up to a year in patients without progression (PACIFIC).
Concurrent chemoradiation then osimertinib until progression (LAURA).
Sequential chemotherapy then radiotherapy, or radiotherapy alone with a hypofractionated schedule; durvalumab afterwards where tolerated.
Grading and steroid treatment of radiation and immune pneumonitis; oesophagitis supportive care; heart dose constraints in planning.
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example TNM stage by PET-CT, brain MRI and mediastinal sampling, EGFR mutation status, PD-L1 expression, Pulmonary function and radiation dose to lung and heart, Circulating tumour DNA after chemoradiation), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include Stage IIIA or IIIB adenocarcinoma, unresectable, without a driver, Stage III squamous cell carcinoma, unresectable, Stage III EGFR-mutated adenocarcinoma.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Unresectable stage III, fit, no EGFR mutation
- For my situation (unresectable stage iii, fit, no egfr mutation), which of the standard options do you recommend and why?Guideline options include: Concurrent platinum-based chemoradiation to 60 Gy with intensity-modulated radiotherapy, then durvalumab for up to a year in patients without progression (PACIFIC).
- Am I a candidate for Durvalumab, Cisplatin, Carboplatin or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of PACIFIC apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Unresectable stage III, EGFR-mutated
- For my situation (unresectable stage iii, egfr-mutated), which of the standard options do you recommend and why?Guideline options include: Concurrent chemoradiation then osimertinib until progression (LAURA).
- Am I a candidate for Osimertinib, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of LAURA apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Unfit for concurrent treatment
- For my situation (unfit for concurrent treatment), which of the standard options do you recommend and why?Guideline options include: Sequential chemotherapy then radiotherapy, or radiotherapy alone with a hypofractionated schedule; durvalumab afterwards where tolerated.
- Am I a candidate for Durvalumab, Carboplatin, Paclitaxel / nab-paclitaxel, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Toxicity
- For my situation (toxicity), which of the standard options do you recommend and why?Guideline options include: Grading and steroid treatment of radiation and immune pneumonitis; oesophagitis supportive care; heart dose constraints in planning.
Any stage
- Are there clinical trials I could join, for example of Study of Pembrolizumab With Concurrent Chemoradiation Therapy Followed by Pembrolizumab With or Without Olaparib in Stage III Non-Small Cell Lung Cancer (NSCLC) (MK-7339-012/KEYLYNK-012), Proton therapy, Pencil-beam scanning and intensity-modulated proton therapy, LAURA?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “Pneumonitis from radiotherapy followed by immunotherapy limits treatment in patients with poor lung function”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “Whether ALK, RET, ROS1 or other driver subtypes should receive targeted rather than immune consolidation is untested”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Unresectable stage III non-small-cell lung cancer: the full pageStage III lung cancer that cannot be removed is treated with chemotherapy and radiotherapy together, aiming at cure. A year of the immunotherapy antibody durvalumab afterwards raised five-year survival from a third to over 40 percent, and for EGFR-mutated tumours osimertinib after chemoradiation holds the disease for years.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
- Stage: How far a cancer has spread, from stage I (small and confined) to stage IV (spread to distant organs).
- TNM staging: TNM staging is the universal system describing tumour size (T), lymph node spread (N), and distant metastasis (M).
- Mediastinum: The space in the middle of the chest between the two lungs, containing the heart, great vessels, windpipe, food pipe and the lymph nodes that lung cancer spreads to first.
- Interstitial lung disease (ILD) / pneumonitis: Interstitial lung disease (ILD) is lung inflammation, a serious side effect of some ADCs (especially Enhertu) and immunotherapy.
- Radiation pneumonitis and lung fibrosis: Inflammation of the lung one to six months after chest radiotherapy, causing cough, breathlessness and fever; usually settles with steroids but can leave permanent scarring.
- Consolidation therapy: Treatment given after a good response to kill the cancer cells that are presumably left but cannot be seen, to make the remission last.
- Circulating tumour DNA (ctDNA): Circulating tumour DNA (ctDNA) consists of fragments of DNA shed by tumour cells into the blood, detectable with sensitive sequencing.
- Chemoradiation (chemoradiotherapy, CRT): Radiotherapy given at the same time as chemotherapy, which sensitises the cancer to radiation.
Every term links to the glossary.