Failure to respond to the initial therapy makes the prognosis more complicated, but there is usually an opportunity for additional therapy and for a good response if the patient is in adequate condition. The type of therapy depends on the treatment that was used initially. If standard doses of ara-C were used (or if no ara-C was used) in a younger patient, usually a regimen centered around higher doses of ara-C would be used. If higher doses of ara-C were already used, most commonly in combination with an anthracycline, other combinations can be used. A common one is a combination of mitoxantrone, etoposide and ara-C. There are also many investigational approaches being used. Importantly, a patient who did not respond or lost response to initial therapy, if a remission is achieved with the “salvage” therapy, a stem cell transplant should be a strong consideration.

A mass in the lung may be evaluated with a number of tests depending on the suspicion that there is a cancer. Many physicians rush to do a biopsy either with a bronchoscope or a x-ray guided needle biopsy. However, if the “mass” appears to be suspicious for lung cancer, in particular, it is often most helpful to obtain a PET-CT scan (PET = “positron emission tomography; CT = computed tomography) scan first to evaluate the extent of the involvement in order to plan the best location for a biopsy. If the lung is quickly biopsied in many circumstances, further biopsies may then be necessary for “staging” of the tumor. If a single PET-CT guided biopsy is performed a diagnosis and staging information can be obtained with one biopsy. Once the best biopsy is evaluated by a pathologist (see above = usually 1-3 days), then the staging information and biopsy results will help determine the next steps in terms of treatment.

After endometrial cancer is diagnosed the next step is surgical treatment. The goal is to have minimally invasive surgery. Robot-assisted or laparoscopic surgery has replaced the open surgical approach to endometrial cancer. However, there are those unusual cases when the only option is an open surgery.

Once mesothelioma is suspected, the next step should be a pathological biopsy. Generally cells obtained from fluid drained from patients with fluid accumulating around the lung is inadequate. Actual pieces of tissue from the lining of the chest is necessary to determine if mesothelioma is present and if so, what subtype of tumor is present. This is best done by a “thoracic” surgeon who has extensive experience in treating mesothelioma patients, both because of the need for sampling appropriate tissue but also because of the need to make appropriate incisions since any needle puncture or surgical incision becomes a site for potential tumor contamination and should not be made in random locations or with more incisions than are absolutely necessary. PET-CT scans are also critical to help determine the “stage” of mesothelioma that is present in order to help determine the treatment options.

Acceptance into a clinical trial begins with the consent process. Risks and potential benefits, as well as other options are explained by your physician or research nurse and also presented to you in writing in the Consent Form – typically a lengthy document. Once you have been fully informed and have consented to the treatment, the next step is to complete the pre-treatment evaluation. This includes a visit with your doctor or nurse, blood tests, scans to determine the extent and location of your cancer, and potentially other tests mandated by the study. At this stage, it is still possible to be “uninvited” from the study. This happens if a test result shows that you don’t meet all the criteria to safely participate. Once the pre-treatment evaluation is complete, the study treatment begins.

The first step is to identify a center of excellence where esophageal disease is a specialty practice. Next is to undergo consultation with an esophageal specialist, this can be a clinician based in surgical or gastroenterology practice. A detailed history will guide a work-up; a series of tests that your doctor will recommend to you. Endoscopy is often the first study performed. This will allow your doctor to directly view the esophagus and to document, describe and biopsy any esophageal abnormalities. If a tumor is encountered, ultrasound performed at the time of the endoscopy will detail the depth of penetration of the tumor into the esophageal wall and the presence of any lymph nodes with potential spread of disease. These important characteristics of the tumor determine the recommended treatment for a newly diagnosed cancer. A CT scan of the chest and abdomen and PET scan are recommended for tumors that are of significant size or penetrating the wall of the esophagus. Both of these tests aid to establish the extent of the tumor spread, otherwise known as stage.

The first thing that needs to happen is a series of tests and analyses, and potentially biopsy and surgery to learn more about the breast cancer. Breast cancer is different for everyone, and as much information as possible must be gathered in order to determine treatment options. These tests likely will take a week or two to perform and analyze the results. In the meantime, do whatever works for you to relax and not worry, whether that is pampering yourself, taking a trip, exercising, shopping, etc.

When you receive the results of the tests, make sure that you have copies of all your medical records (mammograms, test results and pathology slides, etc.) so you can have them for future consultations and appointments. You can get this information at any time, all you need to do is ask for it.

It is also recommended that you get a second opinion, or even a third or fourth, to help you feel more comfortable with your options. This will also help you to begin selecting your medical team. You will get a feel for the physicians that are the best fit for you and that will listen and spend time with you.

After you evaluate the test results and discuss your options with your medical team, the next step will be to decide on your treatment plan. The good news is that there will more than likely be quite a few options to choose from. There will be a lot of information to understand. The medical team and your personal support team will be helpful during this process. Make sure to ask a lot of questions.

Once a patient is diagnosed with non-small cell lung cancer, and then completes staging studies that confirm that the cancer has metastasized, the treatment plan is created. I will sit down with the patient, and hopefully his/her loved ones, to explain the diagnosis and discuss the prognosis. This is often a very anxiety-provoking discussion, but important for patients to understand so they can go into treatment with their eyes open. Metastatic lung cancer is treatable, and the treatments are better than they ever have been in the past, but unfortunately nothing can cure metastatic lung cancer. All treatments are given with the goal of prolonging life for as long as possible while trying to maintain a patient’s quality of life as close to normal as possible.

Based on the specific type of lung cancer we will discuss either standard therapy or participation in a clinical trial. Standard therapy for most patients consists of chemotherapy with a combination of 2 or 3 drugs, usually given every 3 weeks for 4-6 treatments with checks along the way to makes sure it is helping. We discuss the potential side effects and what we will do to manage them, and make arrangement to start as soon as feasible. For some patients, special tests can identify molecular targets that direct us to use different drugs, called targeted agents. The 2 target-drug combinations in use in 2013 are epidermal growth factor receptor (EGFR) mutations and the oral drug erlotinib (Tarceva), and anaplastic lymphoma kinase (ALK) gene fusions and the oral drug crizotinib (Xalkori). These genetic changes are present in about 10% and 4% of non-small cell lung cancers respectively, but are tested for in all new patients.

Finally, we usually discuss the options of participation in a clinical trial, which usually involves the best available chemotherapy or targeted drug PLUS a new drug (or sometimes a placebo) which is being tested to see if it is better than the current combination. We do not do true placebo trials when we have proven treatments, so patients will always get at least the best available standard therapy on a trial.

After a typical craniotomy for tumor removal, patients are often in the hospital for about 5 days with a recovery period of about 2 weeks. However, there is a great variability in these times related to the location of the tumor, patient age, and a patient's general medical condition at the time of surgery. Once a tumor has been removed, additional treatments, if necessary, can be required based on the type of tumor/diagnosis. In some instances, external beam radiation or Gamma Knife Radiosurgery would be performed following surgery. Chemotherapy may also be part of a treatment plan following the removal of a brain tumor.

First radiologic studies such as a CT scan or a PET scan is done. If lung cancer is highly suspected, and appears early stage, then surgical resection is suggested if the patient is healthy enough and has good pulmonary reserve. If the disease is suspected to be advanced, then tissue diagnosis is needed. This can be obtained either through transthoracic needle biopsy, transbronchial biopsy, or endoscopic bronchial ultrasound. If the case is unusual, difficult, or more advanced disease, the patient should be evaluated at a center which deals with lung cancer routinely.