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Stereotactic and hypofractionated radiotherapy for high risk lung tumors
Tekatli, H.
2018
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Tekatli, H. (2018). Stereotactic and hypofractionated radiotherapy for high risk lung tumors.
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Chapter 2
Editorial
The curative treatment of stage I
non-small cell lung cancer
S. Senan
H. Tekatli
Curative treatment of stage I NSCLC
27
2
The optimal curative treatment of stage I non-small cell lung cancer (NSCLC) remains controversial. An anatomical surgical resection with systematic mediastinal lymph node assessment is currently the guideline-specified treatment of stage I NSCLC. For patients who are ineligible or unwilling to undergo surgery, stereotactic ablative radiotherapy (SABR) is the preferred treatment.1 Recent data from comparative effectiveness research, a method which uses all available patient data in order to answer relevant clinical questions, has led to these guidelines being questioned.2 Almost 55% of the Dutch thoracic oncologists now consider SABR and surgery as clinically equivalent treatment options in stage I NSCLC. This proportion varies between different thoracic oncological specialists, ranging from 18% of thoracic surgeons, 49% of pulmonologists, and 83% of radiation oncologists.3 Although prospective data from randomized controlled trials are lacking, a pooled analysis of two randomized studies, both of which were terminated due to poor accrual, revealed similar progression free survivals between SABR and surgery, and suggested that SABR could result in a better overall survival in operable clinical stage I NSCLC.4
In the 6th issue of the Netherlands Journal of Oncology (Nederlands Tijdschrift voor Oncolo-gie), Kastelijn and colleagues compared outcomes of SABR (in 53 patients) and a surgical resection (in 175 patients) using either a video-assisted thoracoscopic surgery (VATS) or an open thoracotomy in stages I-II NSCLC.5 The authors used propensity score matching to correct for confounding baseline patient characteristics. The findings from this high volume institution, where adequate lymph node assessment was performed, again showed that progression free survivals were similar between SABR and surgery, a finding consistent with previous Dutch studies.2,5–9
The ability to administer adjuvant chemotherapy in cases where a lymph node metastasis is found, has been considered as a major advantage of a surgical resection. However, no such confirmatory data are available to show superior survival outcomes following a nodal dis-section in NSCLC, including the study of Kastelijn et al., where a surgical upstaging occurred in 22% of patients. This is not surprising as similar outcomes were observed in previous studies after comprehensive lymph node dissections in the treatment of NSCLC, breast cancer, esophagus cancer, and melanomas with occult lymph node metastases.10–13
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28
A development referred by Kastelijn et al. is the so-called ‘personalized treatment model’. Shared decision making becomes increasingly relevant with the growing evidence of com-parable outcomes after surgery and SABR.17,18 It is important to appreciate that in the case of a preference sensitive decision, the advantages and disadvantages of a decision might be of a different relevance for patients. Specific patient reported outcome measurements (PROMs), such as quality of life after a surgical resection, might be important for some patients.2,19,20 Besides disease-related outcomes, the financial impact of cancer treatment can be significant as well.21,22 Future studies reporting these outcomes might be useful to generate a decision tool in personalized medicine for the treatment of lung cancer.
Table 1 - Comparative effectiveness research in the curative treatment of early stage non-small cell lung cancer
(NSCLC) in the Netherlands
Author Study design Study cohort (n)
Overall survival Disease free survival Surgery SABR Surgery SABR
Verstegen6 Propensity score
matching
Surgery = 64 SABR = 64
3 yr: 77% 3 yr: 80% 3 yr: 63% 3 yr: 79% Mokhles7 Propensity score
matching
Surgery = 73 SABR = 73
5 yr: 80% 5 yr: 53% 5 yr: 76% 5 yr: 70% Van den Berg8 Adjustment for prognostic variables Surgery = 143 SABR = 197
5 yr: 58%* 5 yr: 32%* 5 yr: 72%* 5 yr: 57%* Rossi9 Unknown Surgery = 66
SABR = 42
3 yr: 81% 3 yr: 80% - -Kastelijn5 Propensity score
matching
Surgery = 175 SABR = 53
3 yr: 70%* 3 yr: 43%* 3 yr: 60%* 3 yr: 39%*
Curative treatment of stage I NSCLC
29
2
REFERENCES
1. Vansteenkiste J, De Ruysscher D, Eberhardt WEE, et al. Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2013;24 Suppl 6(SUPPL.6):vi89-98. 2. Louie A, Palma DA, Dahele M, Rodrigues
GB, Senan S. Management of early-stage non-small cell lung cancer using stereo-tactic ablative radiotherapy: Controversies, insights, and changing horizons. Radiother Oncol. 2015;114(2):138-147.
3. Hopmans W, Zwaan L, Senan S, et al. Differences between pulmonologists, thoracic surgeons and radiation on-cologists in deciding on the treatment of stage I non-small cell lung cancer: A bi-nary choice experiment. Radiother Oncol. 2015;115(3):361-366.
4. Chang JY, Senan S, Paul MA, et al. Ste-reotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung cancer: a pooled analysis of two randomised trials. Lancet Oncol. 2015;16(6):630-637.
5. Kastelijn E, El Sharouni S, Hofman F, et al. Clinical outcomes in stage I-II non-small cell lung cancer treated with stereotactic body radiotherapy or surgical resection. Ned Tijdschr voor Oncol. 2015;6:213-220. 6. Verstegen NE, Oosterhuis JWA, Palma DA,
et al. Stage I–II non-small-cell lung cancer treated using either stereotactic ablative radiotherapy (SABR) or lobectomy by vid-eo-assisted thoracoscopic surgery (VATS): outcomes of a propensity score-matched analysis. Ann Oncol. 2013;24(6):1543-1548.
7. Mokhles S, Verstegen N, Maat APWM, et al. Comparison of clinical outcome of stage I non-small cell lung cancer treated surgi-cally or with stereotactic radiotherapy: Results from propensity score analysis. Lung Cancer. 2015;87(3):283-289.
8. van den Berg LL, Klinkenberg TJ, Groen HJM, Widder J. Patterns of recurrence and survival after surgery or stereotactic ra-diotherapy for early stage NSCLC. J Thorac Oncol. 2015;10(5):826-831.
9. Rossi M, Peulen H, van Tinteren H, et al. Out-come after SBRT for potentially operable NSCLC patients. Ann Oncol. 2015;26(Suppl 1):2015.
10. Su S, Scott WJ, Allen MS, et al. Patterns of survival and recurrence after surgical treatment of early stage non–small cell lung carcinoma in the ACOSOG Z0030 (ALLIANCE) trial. J Thorac Cardiovasc Surg. 2014;147(2):747-753.
11. Lizarraga IM, Weigel RJ. Axillary lymph node dissection for breast cancer: Primum non nocere. Eur J Surg Oncol. 2015;41(8):955-957.
12. Van der Schaaf M, Johar A, Wijnhoven B, Lagergren P, Lagergren J. Extent of lymph node removal during esophageal cancer surgery and survival. J Natl Cancer Inst. 2015;107(5).
13. Leiter U, Stadler R, Mauch C, et al. Survival of SLNB-positive melanoma patients with and without complete lymph node dissection: A multicenter, randomized DECOG trial. J Clin Oncol. 2015;33(18_ suppl):LBA9002-LBA9002.
14. DICA Jaarraportage. 2013. Available at: https://www.dica.nl/jaarrapportage-2013/ Accessed August 1, 2015.
15. Paul S, Isaacs AJ, Treasure T, Altorki NK, Sedrakyan A. Long term survival with thoracoscopic versus open lobectomy: propensity matched comparative analysis using SEER-Medicare database. BMJ. 2014;349(oct02 3):g5575-g5575. 16. Rajaram R, Ju MH, Bilimoria KY, Ko CY,
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17. Lawler M, Le Chevalier T, Murphy MJ, et al. A Catalyst for Change: The European Cancer Patient’s Bill of Rights. Oncologist. 2014;19(3):217-224.
18. Salzburg statement on shared decision making. BMJ. 2011;342:d1745-d1745. 19. Poghosyan H, Sheldon LK, Leveille SG,
Cooley ME. Health-related quality of life after surgical treatment in patients with non-small cell lung cancer: a systematic review. Lung Cancer. 2013;81(1):11-26. 20. Fagundes CP, Shi Q, Vaporciyan AA, et al.
Symptom recovery after thoracic surgery: Measuring patient-reported outcomes with the MD Anderson Symptom Inventory. J Thorac Cardiovasc Surg. 2015;150(3):613-619.e2.
21. Zafar SY, McNeil RB, Thomas CM, Lathan CS, Ayanian JZ, Provenzale D. Population-based assessment of cancer survivors’ financial burden and quality of life: a prospective cohort study. J Oncol Pract. 2015;11(2):145-150.
