How to manage non-small cell lung cancer at 71?

Question

Hello doctor,

My father is 71, and we received the devastating news of stage 4 NSCLC last week after a chest CT revealed a large right upper lobe mass with what appear to be liver lesions and possible adrenal involvement.

The pulmonologist who gave us the diagnosis said that further imaging is needed, but there seems to be some back and forth within the team about the next steps, and we feel like we are losing precious time.

His biopsy has been sent for molecular profiling, and we are waiting for PD-L1 and mutation results. His LDH is elevated at 310, and his albumin is low at 2.9, which is making us very anxious about how quickly things might be progressing. We live in a smaller city, and accessing specialists quickly is a challenge for us.

My question is whether I should arrange a PET scan at the stage 4 NSCLC diagnosis, or if the CT and biopsy are enough to begin treatment. I have read that PET scans can detect areas that CT scans might miss, and I worry that skipping it could affect how accurately he is treated.

His cardiologist also noted a mild pericardial effusion on an echocardiogram last month, and we are unsure whether this is related to the NSCLC or a separate issue. Every day of waiting feels unbearable right now, and we want to make sure nothing is being missed before treatment begins.

Please help.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

In stage 4 non-small cell lung cancer (NSCLC), the most important first steps are confirming the diagnosis with a biopsy and sending the tumor for molecular testing. Tests such as epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), ROS proto-oncogene 1 (ROS1), Kirsten rat sarcoma viral oncogene homolog (KRAS), and programmed death ligand 1 (PD-L1) are very important because they help determine whether targeted therapy or immunotherapy can be used.

In many patients, these treatments can work better than traditional chemotherapy, so doctors usually wait for these results before starting treatment unless the patient is very unstable.

Regarding the positron emission tomography scan (PET scan), since the computed tomography scan (CT scan) has already shown distant metastases such as liver or adrenal lesions, the disease is already considered stage 4. In such situations, a PET scan is not always necessary before starting systemic treatment. Some centers still perform it to better map the disease, but skipping it usually does not change the treatment plan.

The elevated lactate dehydrogenase (LDH) and lower albumin can occur in many conditions, including advanced cancer, inflammation, or nutritional issues. These values alone do not determine how aggressive the cancer is and must be interpreted in the overall clinical context.

A mild pericardial effusion can sometimes be unrelated and may occur due to other causes, such as inflammation or heart conditions. If it is small and not causing symptoms, doctors usually monitor it.

The most important step now is waiting for the molecular and programmed death ligand 1 (PD-L1) test results because these results will guide the best treatment choice. If a targetable mutation is found, oral targeted therapy may be very effective. If no mutation is present, immunotherapy with or without chemotherapy is usually considered.

If possible, please share the biopsy report and molecular or next-generation sequencing (NGS) report. I will be happy to guide you further regarding treatment options.

I hope this helps.

Kindly follow up if you have more concerns.

Thank you.