The first 60 days: Unresectable stage III non-small-cell lung cancer

Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.

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.

1. 1.Unresectable stage III, fit, no EGFR mutationNCCN Guidelines: Non-Small Cell Lung Cancer

   Concurrent platinum-based chemoradiation to 60 Gy with intensity-modulated radiotherapy, then durvalumab for up to a year in patients without progression (PACIFIC).

   PACIFICDurvalumabChemoradiation (chemoradiotherapy, CRT)IMRT / IGRT (modern external beam)CisplatinCarboplatinEtoposidePemetrexedPaclitaxel / nab-paclitaxelConsolidation therapy
2. 2.Unresectable stage III, EGFR-mutatedNCCN Guidelines: Non-Small Cell Lung Cancer

   Concurrent chemoradiation then osimertinib until progression (LAURA).

   LAURAOsimertinibChemoradiation (chemoradiotherapy, CRT)
3. 3.Unfit for concurrent treatmentNCCN Guidelines: Non-Small Cell Lung Cancer

   Sequential chemotherapy then radiotherapy, or radiotherapy alone with a hypofractionated schedule; durvalumab afterwards where tolerated.

   IMRT / IGRT (modern external beam)Hypofractionated radiotherapyDurvalumabCarboplatinPaclitaxel / nab-paclitaxel
4. 4.ToxicityNCCN Guidelines: Non-Small Cell Lung Cancer

   Grading and steroid treatment of radiation and immune pneumonitis; oesophagitis supportive care; heart dose constraints in planning.

   Radiation pneumonitis and lung fibrosisInterstitial lung disease (ILD) / pneumonitisIMRT / IGRT (modern external beam)Proton therapy

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.

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.

• A Global Study to Assess the Effects of Durvalumab + Domvanalimab Following Concurrent Chemoradiation in Participants With Stage III Unresectable NSCLCPhase 3 · active · NCT05211895A Phase III, Randomised, Double-blind, Placebo-controlled, Multicentre, International Study of Durvalumab Plus Domvanalimab(AB154) in Participants With Locally Advanced (Stage III), Unresectable Non-small Cell Lung Cancer Whose Disease Has Not Progressed Following Definitive Platinum-based Concurrent Chemoradiation Therapy
• A Global Study to Assess the Effects of Durvalumab With Oleclumab or Durvalumab With Monalizumab Following Concurrent Chemoradiation in Patients With Stage III Unresectable Non-Small Cell Lung CancerPhase 3 · active · NCT05221840A Phase III, Double-blind, Placebo-controlled, Randomised, Multicentre, International Study of Durvalumab Plus Oleclumab and Durvalumab Plus Monalizumab in Patients With Locally Advanced (Stage III), Unresectable Non-small Cell Lung Cancer (NSCLC) Who Have Not Progressed Following Definitive, Platinum-Based Concurrent Chemoradiation Therapy
• A Phase III Study to Assess the Effects of Almonertinib Following Chemoradiation in Patients With Stage III Unresectable Non-small Cell Lung CancerPhase 3 · recruiting · NCT04951635A Phase III, Randomised, Double-blind, Placebo-controlled, Multi-centre Study of Almonertinib as Maintenance Therapy in Patients With Locally Advanced, Unresectable EGFR Mutation-positive Non-Small Cell Lung Cancer (Stage III) Who Have Not Progressed Following Definitive, Platinum-based Chemoradiation Therapy
• A Study Comparing BL-B01D1 in Combination With Osimertinib Versus Osimertinib Alone in Patients With Locally Advanced, Unresectable EGFR-mutated Non-sPhase 3 · recruiting · NCT07640789A Phase III Randomized Controlled Clinical Study Comparing BL-B01D1 in Combination With Osimertinib Versus Osimertinib Alone in Patients With Locally Advanced, Unresectable EGFR-mutated Non-small Cell Lung Cancer(Stage III) Whose Disease Has Not Progressed Following Definitive Platinum-based Chemoradiation Therapy(PANKU-Lung08)
• A Study Evaluating the Efficacy and Safety of Multiple Therapies in Cohorts of Participants With Locally Advanced, Unresectable, Stage III Non-Small CPhase 3 · active · NCT05170204A Phase I-III, Multicenter Study Evaluating the Efficacy and Safety of Multiple Therapies in Cohorts of Patients Selected According to Biomarker Status, With Locally Advanced, Unresectable, Stage III Non-Small Cell Lung Cancer

Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.

• Free in oncologyFree testing, helplines, rides and lodging, second opinions and trial travel help, with who is eligible.
• Financial helpManufacturer programmes, national schemes and charities by country and product.
• Second opinionExpert centres for this cancer in your country and how referral works.

• 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.