PACIFIC: Time for a surgical IIIA uprising

Surgical decision-making in advanced-stage non–small cell lung cancer is influenced by more than just guidelines

Objective

This qualitative study sought to uncover factors that influence decisions to offer curative-intent surgery for patients with advanced-stage (stage IIIB/IV) non–small cell lung cancer.

Methods

A trained interviewer conducted open-ended, semistructured telephone interviews with cardiothoracic surgeons in the United States. Participants were recruited from the Thoracic Surgery Outcomes Research Network, with subsequent diversification through snowball sampling. Four hypothetical clinical scenarios were presented, each demonstrating varying levels of ambiguity with respect to international guideline recommendations. Interviews continued until thematic saturation was reached. Interview transcripts were coded using inductive reasoning and conventional content analysis.

Results

Of the 27 participants, most had been in practice for ≤20 years (n = 23) and were in academic practice (n = 18). When considering nonguideline-concordant surgeries, participants were aware of relevant guidelines but acknowledged their limitations for unique scenarios. Surgeons perceived that a common barrier to offering surgery is incomplete nonsurgeon physician understanding of surgical capabilities or expected morbidity; and that improved education is necessary to correct these misperceptions. Surgeons expressed concern that undertaking a controversial resection for an individual patient could fracture trust built in long-term professional relationships. Surgeons may face pressure from patients to operate despite a low expectation of clinical benefit, leading to emotional turmoil for the patient and surgeon.

Conclusions

This qualitative study generates the hypothesis that the scope of current guidelines, availability of clinical trial protocols, perceived surgical knowledge among nonsurgeon colleagues, interprofessional relationships, and emotional pressure all influence a surgeon's willingness to offer curative-intent surgery for patients with advanced-stage non–small cell lung cancer.

How Effective Is Neoadjuvant Therapy Followed by Surgery for Pathologic Single-Station N2 Non-Small Cell Lung Cancer?

The optimal treatment strategy for pathologic single-station N2 (pN2a1) non-small cell lung cancer (NSCLC)-surgery first followed by adjuvant treatment (SF) or neoadjuvant therapy followed by surgery (NS)-remains unclear. We compared disease-free survival (DFS) and overall survival (OS) after NS versus SF for pN2a1 NSCLC. We retrospectively identified patients with pN2a1 NSCLC resected between 2000 and 2018. Patients in the SF group had cN0 disease and were treated with surgery before adjuvant chemotherapy; patients in the NS group had known preoperative nodal disease, cN2 disease, and were treated with neoadjuvant therapy before surgery. The matching-weights procedure was applied to generate a cohort with similar characteristics between groups. DFS and OS were calculated using the Kaplan-Meier approach and compared between groups using weighted log-rank test and Cox proportional hazards models. We identified 227 patients with pN2a1 disease: 121 treated with SF and 106 with NS. After the matching-weights procedure, 5- and 10-year DFS were 45% and 27% for SF versus 26% and 21% for NS (log-rank P = 0.056; hazard ratio [HR], 1.61; 95% confidence interval [CI], 0.98-2.65); 5- and 10-year OS were 49% and 30% for SF versus 43% and 20% for NS (log-rank P = 0.428; HR, 1.24; 95% CI, 0.67-2.28). SF and NS for pN2a1 NSCLC resulted in similar survival. A study comparing SF for known preresectional pN2a1 with occult pN2a1 disease could be a next step. Further investigation of SF for known N2a1 versus occult pN2a1 disease could power a clinical trial focused on N2a NSCLC.

Video-assisted thoracoscopic surgery as the gold standard for lung cancer surgery

Surgical resection remains the only effective means of cure in the vast majority of patients with early-stage lung cancer. It can be performed via a traditional open approach (particularly thoracotomy) or a minimally invasive approach. VATS is 'keyhole' surgery in the chest, and was first used for lung cancer resection in the early 1990s. Since then, a large volume of evolving clinical evidence has confirmed that VATS lung cancer resection offered proven safety and feasibility, better patient-reported post-operative outcomes, less surgical trauma as quantified by objective outcome measures and equivalent or better survival than open surgery. This has firmly established VATS as the surgical approach of choice for early-stage lung cancer today. Although impressive new non-surgical lung cancer therapies have emerged in recent years, VATS is also being constantly rejuvenated by the development of 'next generation' VATS techniques, the refinement of VATS sublobar resection for selected patients, the utilization of bespoke post-operative recovery programmes for VATS and the synthesis of VATS into multi-modality lung cancer therapy. There is little doubt that VATS will remain as the gold standard for lung cancer surgery for the foreseeable future.