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The Future of Treating Oligometastatic Lung Cancer Is Personalized Care

*December 2022* Jill Feldman, EGFR Resisters Co-Founder

As someone who has been fighting lung cancer indirectly and directly for almost 40 years, I have witnessed and celebrated the rapidly changing landscape of lung cancer diagnosis and treatment. After losing 2 grandparents and my dad to lung cancer when I was 13 and then my mom and Aunt Dede when I was in my 20s, I got involved in lung cancer advocacy in 2001. At the time, the only distinction doctors could make was whether a person had small cell or non-small cell lung cancer (NSCLC), with only 3 treatment options to offer their patients: surgery, radiation, or chemotherapy.

Then, in 2009, I discovered I had EGFR-mutant lung cancer. There are no words to describe how it felt at 39 years of age, with 4 small kids, to be diagnosed with lung cancer — the same disease that I watched kill my mom and my dad just months after diagnosis. When my disease was diagnosed, research was moving in the right direction, but there still weren’t any promising advancements that convinced me the path would change. However, the pace of discovery over the past decade has been remarkable, and I have been fortunate to benefit from the revolution in lung cancer research and care.

Stereotactic body radiation therapy was life-changing and probably life-saving for me. Although it wasn’t standard of care for intrapulmonary metastasis, I was able to use stereotactic body radiation therapy as needed for 5 years. It played a critical role in managing the cancer in my lungs and allowed me to delay going back on systemic therapy with horrible side effects. It also gave research time to advance and develop new treatments, like the one I am on now.

The tide has turned in lung cancer research, and with it, so must the paradigm on how to treat people with stage IV NSCLC. Advancements in cancer biology, diagnostics, and new surgical and radiation therapy techniques, along with targeted therapies and immunotherapies, are driving progress, and the dramatic increase in survival illustrates the power of research. Once considered a death sentence, today, we expect patients with stage IV lung cancer to live years, even decades.

We have learned that the orderly process of progression from a primary tumor to lymph nodes and then metastasis to distant organs is complex and that not all metastatic lung cancer is the same. We know that patients with limited (oligo)metastatic disease have a different prognosis than patients with widely metastatic disease, and we’ve seen the progression-free and quality-of-life benefits when local therapy is used in patients with oligometastatic disease. Still, the rationale for localized therapy in this population has been primarily based on the number of metastatic sites. It doesn’t account for the growing knowledge of the genomic makeup of cancer or the tumor microenvironment. As our understanding of the biology of lung cancer evolves and systemic therapies continue to improve, the importance of local disease control will be critical in maintaining survival and quality of life.

Local therapy for treating oligometastatic NSCLC continues to be a controversial and complex topic, with constant debate regarding how to define it, and no large randomized studies that validate an overall survival benefit. There are ongoing studies, and we anxiously await the data, but time is not a luxury patients have. Meanwhile, following evidence-based guidelines doesn’t always reflect the modern reality of treating stage IV lung cancer in a routine clinic. Read more.