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Craig C, Johnston J, Goodley P, Bishop P, Al-Najjar H, Brown L, Gallagher J, Sundar R, Upperton S, Callister M, Meek D, Succony L, Parvez W, Tufail M, Jayasekera G, Maclay J, Livesey A, Woolhouse I, Smith N, Bibby A, Evison M. What Is the Accuracy of Clinical Staging for Stage III-Single-station N2 NSCLC? A Multi-Centre UK Study. JTO Clin Res Rep 2024; 5:100694. [PMID: 39161961 PMCID: PMC11332836 DOI: 10.1016/j.jtocrr.2024.100694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 05/19/2024] [Accepted: 05/25/2024] [Indexed: 08/21/2024] Open
Abstract
Introduction Single-station N2 (ssN2) versus multi-station N2 has been used as a selection criterion for treatment recommendations between surgical versus non-surgical multimodality treatment in stage III-N2 NSCLC. We hypothesized that clinical staging would be susceptible to upstaging on pathologic staging and, therefore, challenge this practice. Methods A retrospective study of prospectively collected routine clinical data for patients with stage III-N2 NSCLC that had completed computed tomography (CT), positron emission tomography (PET), and staging endobronchial ultrasound (EBUS) and had been confirmed clinical stage III-ssN2 at multidisciplinary team discussion and went on to complete surgical resection as the first treatment to provide pathologic staging. The study was completed in two cohorts (A) across a single cancer alliance in England (Greater Manchester) January 1, 2015 to December 31, 2018 and (B) across five United Kingdom centers to validate the findings in part A January 1, 2016 to December 31, 2020. Results A total of 115 patients met the inclusion criteria across cohort A (56 patients) and cohort B (59 patients) across 15 United Kingdom hospitals. The proportion of cases in which clinical stage III-ssN2 was upstaged to pathologic stage III-multi-station N2 was 34% (19 of 56) in cohort A, 32% in cohort B (19 of 59), and 33% across the combined study cohort (38 of 115). Most patients had a single radiologically abnormal lymph node on CT and PET (88%, 105 of 115). In the majority, the reasons for missed N2 disease on staging EBUS were due to inaccessible (stations 5, 6, 8, 9) N2 nodes at EBUS (34%, 13 of 38) and accessible lymph nodes not sampled during staging EBUS as not meeting sampling threshold (40%, 15 of 38) rather than false-negative sampling during EBUS (26%, 10 of 38). Conclusions During multidisciplinary team discussions, clinicians must be aware that one-third of patients with stage III-ssN2 on the basis of CT, PET, and staging EBUS do not truly have ssN2 and this questions the use of this criterion to define treatment recommendations.
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Affiliation(s)
- Christopher Craig
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Janet Johnston
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Patrick Goodley
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Paul Bishop
- Department of Thoracic Histopathology, Clinical Support Services, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Haider Al-Najjar
- Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Louise Brown
- North Manchester General Hospital, Manchester, United Kingdom
| | - Joanna Gallagher
- Macclesfield Hospital, East Cheshire NHS Trust, Macclesfield, United Kingdom
| | - Ramachandran Sundar
- Royal Albert Edward Infirmary, Wrightington, Wigan & Leigh NHS Foundation Trust, Wigan, United Kingdom
| | - Sara Upperton
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | | | - David Meek
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Laura Succony
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Wadood Parvez
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Muhammad Tufail
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Geeshath Jayasekera
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - John Maclay
- Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Alana Livesey
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Ian Woolhouse
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | | | - Anna Bibby
- North Bristol NHS Trust, Bristol, United Kingdom
| | - Matthew Evison
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Manchester Academic Health Science Centre (MAHSC), Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
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Verma S, Breadner D, Mittal A, Palma DA, Nayak R, Raphael J, Vincent M. An Updated Review of Management of Resectable Stage III NSCLC in the Era of Neoadjuvant Immunotherapy. Cancers (Basel) 2024; 16:1302. [PMID: 38610980 PMCID: PMC11010993 DOI: 10.3390/cancers16071302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 03/15/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Immune-checkpoint inhibitors (ICIs) have an established role in the treatment of locally advanced and metastatic non-small cell lung cancer (NSCLC). ICIs have now entered the paradigm of early-stage NSCLC. The recent evidence shows that the addition of ICI to neoadjuvant chemotherapy improves the pathological complete response (pCR) rate and survival rate in early-stage resectable NSCLC and is now a standard of care option in this setting. In this regard, stage III NSCLC merits special consideration, as it is heterogenous and requires a multidisciplinary approach to management. As the neoadjuvant approach is being adopted widely, new challenges have emerged and the boundaries for resectability are being re-examined. Consequently, it is ever more important to carefully individualize the treatment strategy for each patient with resectable stage III NSCLC. In this review, we discuss the recent literature in this field with particular focus on evolving definitions of resectability, T4 disease, N2 disease (single and multi-station), and nodal downstaging. We also highlight the controversy around adjuvant treatment in this setting and discuss the selection of patients for adjuvant treatment, options of salvage, and next line treatment in cases of progression on/after neoadjuvant treatment or after R2 resection. We will conclude with a brief discussion of predictive biomarkers, predictive models, ongoing studies, and directions for future research in this space.
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Affiliation(s)
- Saurav Verma
- Division of Medical Oncology, Department of Oncology, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 3K7, Canada; (S.V.); (D.B.); (J.R.)
- London Regional Cancer Program, London Health Sciences Centre, London, ON N6A 5W9, Canada; (D.A.P.); (R.N.)
| | - Daniel Breadner
- Division of Medical Oncology, Department of Oncology, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 3K7, Canada; (S.V.); (D.B.); (J.R.)
- London Regional Cancer Program, London Health Sciences Centre, London, ON N6A 5W9, Canada; (D.A.P.); (R.N.)
| | - Abhenil Mittal
- Division of Medical Oncology, Northeast Cancer Centre, Ramsey Lake Health Centre, Sudbury, ON P3E 5J1, Canada;
| | - David A. Palma
- London Regional Cancer Program, London Health Sciences Centre, London, ON N6A 5W9, Canada; (D.A.P.); (R.N.)
- Division of Radiation Oncology, Department of Oncology, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 3K7, Canada
| | - Rahul Nayak
- London Regional Cancer Program, London Health Sciences Centre, London, ON N6A 5W9, Canada; (D.A.P.); (R.N.)
- Division of Thoracic Surgery, Department of Oncology, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 3K7, Canada
| | - Jacques Raphael
- Division of Medical Oncology, Department of Oncology, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 3K7, Canada; (S.V.); (D.B.); (J.R.)
- London Regional Cancer Program, London Health Sciences Centre, London, ON N6A 5W9, Canada; (D.A.P.); (R.N.)
| | - Mark Vincent
- Division of Medical Oncology, Department of Oncology, Schulich School of Medicine & Dentistry, Western University, London, ON N6A 3K7, Canada; (S.V.); (D.B.); (J.R.)
- London Regional Cancer Program, London Health Sciences Centre, London, ON N6A 5W9, Canada; (D.A.P.); (R.N.)
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3
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Scherpereel A, Martin E, Brouchet L, Corre R, Duruisseaux M, Falcoz PE, Giraud P, Le Péchoux C, Wislez M, Alifano M. Reaching multidisciplinary consensus on the management of non-bulky/non-infiltrative stage IIIA N2 non-small cell lung cancer. Lung Cancer 2023; 177:21-28. [PMID: 36682142 DOI: 10.1016/j.lungcan.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/06/2023] [Accepted: 01/15/2023] [Indexed: 01/19/2023]
Abstract
INTRODUCTION The optimal management of patients with non-bulky/non-infiltrative stage IIIA N2 non-small cell lung cancer (NSCLC) remains controversial. In this modified Delphi study from France, we aimed to generate agreement through multidisciplinary decision-making on the clinical management of patients with non-bulky/non-infiltrative N2 NSCLC. METHODS An expert panel of 30 physicians from different specialities completed two Delphi rounds of a 76-item questionnaire, pertaining to: pathological confirmation of N2 disease; initial treatment approach; treatment approach in case of disease progression/stability following neoadjuvant chemotherapy; treatment approach taking into account various patient and tumour characteristics. Each questionnaire item was scored using a 9-point Likert scale. Consensus in agreement was achieved if ≥ 80 % of responses to a questionnaire item were scored between 7 and 9 and if the median value of the score to the item was ≥ 7. RESULTS Regarding the pathologic confirmation of N2 disease, agreement (up to 100 %) was reached on endobronchial ultrasound/endoscopic ultrasound as the preferred method of initial mediastinal staging for paratracheal lymph nodes. There was also panellist agreement (up to 93 %) on the adoption as first-line treatment of surgery and (neo)adjuvant chemotherapy in patients with single-station disease, and of concurrent chemoradiotherapy followed by adjuvant immunotherapy in those with multi-station N2 disease. Panellists further agreed on the use of a non-surgical strategy, i.e., concurrent chemoradiotherapy with adjuvant immunotherapy, in patients with single-station N2 disease in case of: involvement of ≥ 2 mediastinal lymph nodes; disease progression following neoadjuvant chemotherapy; compromised cardiopulmonary function if compatible with radiotherapy; anticipated right pneumonectomy. CONCLUSIONS This Delphi study reinforces the importance of multidisciplinary discussions leading to the best individual approach to the clinical management of patients with non-bulky/non-infiltrative N2 NSCLC, a challenging heterogeneous population.
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Affiliation(s)
- Arnaud Scherpereel
- Pulmonary and Thoracic Oncology Department, University of Lille, CHU Lille, INSERM, OncoThAI, Institut Coeur Poumon, Lille, France
| | - Etienne Martin
- Department of Radiation Oncology, Centre George-François Leclerc, Dijon, France
| | - Laurent Brouchet
- Department of Thoracic Surgery, Larrey Hospital, CHU Toulouse, Toulouse, France
| | - Romain Corre
- Department of Pneumology, Hospital Centre De Cornouaille, Quimper, France
| | - Michaël Duruisseaux
- Department of Respiratory Medicine, Louis Pradel Hospital, Civil Hospices of Lyon, Lyon, France; Cancer Research Centre of Lyon, UMR INSERM 1052 CNRS 5286, Lyon, France; Claude Bernard University Lyon 1, University of Lyon, Lyon, France
| | | | - Philippe Giraud
- Department of Radiation Oncology, Georges Pompidou European Hospital, AP-HP, Paris Centre University Hospital, Paris, France
| | - Cécile Le Péchoux
- Department of Radiation Oncology, International Center for Thoracic Cancers (CICT), Gustave Roussy, Villejuif, France
| | - Marie Wislez
- Oncology Thoracic Unit, Pulmonology Department, Cochin Hospital, Paris Centre University Hospital, AP-HP, Paris, France; INSERM, Team Inflammation, Complement, and Cancer, Cordeliers Research Centre, Sorbonne University, Paris Cité University, Paris, France
| | - Marco Alifano
- Department of Thoracic Surgery, Paris Centre University Hospital, AP-HP, Paris, France; INSERM U1138, Integrative Cancer Immunology, University of Paris, Paris, France.
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Evison M, Maconachie R, Mercer T, Daly CH, Welton NJ, Aslam S, West D, Navani N. What is the optimal management of potentially resectable stage III-N2 NSCLC? Results of a fixed-effects network meta-analysis and economic modelling. ERJ Open Res 2023; 9:00299-2022. [PMID: 37020838 PMCID: PMC10068518 DOI: 10.1183/23120541.00299-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/20/2022] [Indexed: 02/05/2023] Open
Abstract
Introduction There is a critical need to understand the optimal treatment regimen in patients with potentially resectable stage III-N2 nonsmall cell lung cancer (NSCLC). Methods A systematic review of randomised controlled trials was carried out using a literature search including the CDSR, CENTRAL, DARE, HTA, EMBASE and MEDLINE bibliographic databases. Selected trials were used to perform a Bayesian fixed-effects network meta-analysis and economic modelling of treatment regimens relevant to current-day treatment options: chemotherapy plus surgery (CS), chemotherapy plus radiotherapy (CR) and chemoradiotherapy followed by surgery (CRS). Findings Six trials were prioritised for evidence synthesis. The fixed-effects network meta-analyses demonstrated an improvement in disease-free survival (DFS) for CRS versus CS and CRS versus CR of 0.34 years (95% CI 0.02-0.65) and 0.32 years (95% CI 0.05-0.58) respectively, over a 5-year period. No evidence of effect was observed in overall survival although point estimates favoured CRS. The probabilities that CRS had a greater mean survival time and greater probability of being alive than the reference treatment of CR at 5 years were 89% and 86% respectively. Survival outcomes for CR and CS were essentially equivalent. The economic model calculated that CRS and CS had incremental cost-effectiveness ratios of £19 000/quality-adjusted life-year (QALY) and £78 000/QALY compared to CR. The probability that CRS generated more QALYs than CR and CS was 94%. Interpretation CRS provides an extended time in a disease-free state leading to improved cost-effectiveness over CR and CS in potentially resectable stage III-N2 NSCLC.
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Affiliation(s)
- Matthew Evison
- Lung Cancer and Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Ross Maconachie
- NICE Centre for Guidelines, National Institute for Health and Care Excellence, Manchester, UK
| | - Toby Mercer
- NICE Centre for Guidelines, National Institute for Health and Care Excellence, Manchester, UK
| | - Caitlin H. Daly
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicky J. Welton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shahzeena Aslam
- Bedford and Addenbrooke's Cambridge University NHS Hospital Trusts, Cambridge, UK
| | - Doug West
- Department of Thoracic Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Neal Navani
- Department of Respiratory Medicine, University College London Hospital, London, UK
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5
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Taylor S, Yorke J, Tsim S, Navani N, Baldwin D, Woolhouse I, Edwards J, Grundy S, Robson J, Rhodes S, Gomes F, Blackhall F, Faivre-Finn C, Evison M. Impact on quality of life from multimodality treatment for lung cancer: a randomised controlled feasibility trial of surgery versus no surgery as part of multimodality treatment in potentially resectable stage III-N2 NSCLC (the PIONEER trial). BMJ Open Respir Res 2021; 8:8/1/e000846. [PMID: 34266853 PMCID: PMC8286764 DOI: 10.1136/bmjresp-2020-000846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 06/15/2021] [Indexed: 12/25/2022] Open
Abstract
Introduction Optimal treatment for ‘potentially resectable’ stage III-N2 non-small cell lung cancer (NSCLC) requires multimodality treatment: local treatment (surgery or radiotherapy) and systemic anticancer therapy. There is no clear evidence of superiority for survival between the two approaches and little research has explored quality of life (QOL). This study will inform the design of a phase III randomised trial of surgery versus no surgery as part of multimodality treatment for stage III-N2 NSCLC with QOL as a primary outcome. Methods and analysis Patient participants will be randomised to receive multimodality treatment (1) with surgery OR (2) without surgery. The Quintet Recruitment Intervention will be used to maximise recruitment. Eligible patients will have ‘potentially resectable’ N2 NSCLC and have received a multidisciplinary team recommendation for multimodality treatment. Sixty-six patients and their carers will be recruited from 8 UK centres. Patient/carer QOL questionnaires will be administered at baseline, weeks 6, 9, 12 and month 6. Semistructured interviews will be conducted. Quantitative data will be analysed descriptively and qualitative data will be analysed using framework analysis. Ethics and dissemination Ethical approval has been obtained. Results will be disseminated via publications, national bodies and networks, and patient and public involvement groups. Trial registration NCT04540757
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Affiliation(s)
- Sally Taylor
- Christie Patient Centred Research, The Christie NHS Foundation Trust, Manchester, UK .,School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Janelle Yorke
- Christie Patient Centred Research, The Christie NHS Foundation Trust, Manchester, UK.,School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Selina Tsim
- Glasgow Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, UK.,Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Neal Navani
- Lungs For Living Research Centre, University College London and Department of Thoracic Medicine, University College London Hospital, London, UK
| | - David Baldwin
- Respiratory Medicine Unit, David Evans Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, Nottinghamshire, UK
| | - Ian Woolhouse
- Department of Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - John Edwards
- Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, Sheffield, UK
| | - Seamus Grundy
- Respiratory Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | | | | | - Fabio Gomes
- Christie Patient Centred Research, The Christie NHS Foundation Trust, Manchester, UK.,Medical Oncology department, The Christie NHS Foundation Trust, Manchester, UK
| | - Fiona Blackhall
- University of Manchester, Manchester, UK.,The Christie NHS Foundation Trust, Manchester, UK
| | - Corinne Faivre-Finn
- University of Manchester, Manchester, UK.,The Christie NHS Foundation Trust, Manchester, UK
| | - Matthew Evison
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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6
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Abstract
For stage III non-small cell lung cancer (NSCLC), approximately a third of patients survive up to 5 years, with decreasing 5-year survival rates for stage IIIB and stage IIIC disease. Although curable, stage III NSCLC encompasses a diverse range of disease presentation, with an equally complex range of multi-modal treatment options, including systemic and local therapies for distant and local disease control, respectively. This complexity results in a number of challenges for the multi-disciplinary team (MDT) in achieving optimal treatment outcomes for patients. As multi-modality treatment is the preferred treatment strategy for all stage III disease, the focus of this article is the key surgical, chemotherapy and radiotherapy clinical trials as well as guidelines that currently outline radical therapy options for patients with both potentially resectable and unresectable stage III NSCLC.
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7
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Iseli T, Berghmans T, Glatzer M, Rittmeyer A, Massard G, Durieux V, Buchsbaum T, Putora PM. Adverse events reporting in stage III NSCLC trials investigating surgery and radiotherapy. ERJ Open Res 2020; 6:00010-2020. [PMID: 32963993 PMCID: PMC7487347 DOI: 10.1183/23120541.00010-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 05/26/2020] [Indexed: 12/25/2022] Open
Abstract
Background Current treatment options for stage III non-small cell lung cancer (NSCLC) consist of different combinations of chemotherapy, surgery, radiotherapy and immunotherapy. Treatment choices are highly individual decisions, in which adverse events (AEs) are relevant for decision-making. This study aims to analyse reporting of AEs in prospective stage III NSCLC trials, focussing on trials including radiotherapy and/or surgery. Methods PubMed was searched for prospective studies dealing with stage III NSCLC from January 1987 to April 2019. Meta-analyses were screened as a positive control. Pearson's Chi-squared test and smooth kernel distribution were used to estimate distributions. Data was resampled using bootstrapping. Results Out of 1193 initially identified studies, 119 met the inclusion criteria. Of these, 31 had a surgical procedure in any study arm. Grade 3 and 4 AEs were reported in 94.12% and 92.44% of the included studies, respectively. Reporting of grade 5 AEs was provided in 87.39% of cases. Grade 1 and 2 AEs were less commonly reported at 53.78% and 63.03%, respectively. One study did not mention any AEs. Of the 31 treatment arms including any form of surgery, AEs were not reported in 10. Overall, 231 different AE items were reported, only 18 of them were included in at least 20% of the analysed studies. Conclusion Overall, AE reporting in stage III NSCLC was inconsistent and inhomogeneous. Studies including surgical study arms often reported only treatment-related deaths in regards of surgical AEs. Underreporting of AEs prohibits the extraction of patient-relevant information for decision-making and represents a suboptimal use of invested resources. Adverse event reporting for stage III NSCLC is inconsistent and inhomogeneous. Surgical studies tend to underreport lower grade adverse effects. Patient-relevant information for decision-making is lost and invested resources are used suboptimally.https://bit.ly/3gLNIYy
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Affiliation(s)
- Thomas Iseli
- Dept of Radiation Oncology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Thierry Berghmans
- Thoracic Oncology Clinic, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Markus Glatzer
- Dept of Radiation Oncology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Achim Rittmeyer
- Dept of Thoracic Oncology, Lungenfachklinik Immenhausen, Immenhausen, Germany
| | - Gilbert Massard
- Lung Transplantation Group, University Hospital Strasbourg, Strasbourg, France
| | - Valérie Durieux
- Dept of Libraries and Information Science, Université Libre de Bruxelles, Brussels, Belgium
| | - Thomas Buchsbaum
- Dept of Radiation Oncology, Stadtspital Triemli, Zurich, Switzerland
| | - Paul Martin Putora
- Dept of Radiation Oncology, Kantonsspital St Gallen, St Gallen, Switzerland.,Dept of Radiation Oncology, Inselspital, University of Bern, Bern, Switzerland
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8
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Iseli T, Fischer GF, Panje CM, Glatzer M, Hundsberger T, Rothermundt C, Schmidt B, Sirén C, Plasswilm L, Putora PM. Insular Decision Criteria in Clinical Practice: Analysis of Decision-Making in Oncology. Oncology 2020; 98:438-444. [DOI: 10.1159/000508132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 04/24/2020] [Indexed: 11/19/2022]
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9
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Evison M, Edwards J, McDonald F, Popat S. Stage III Non-small Cell Lung Cancer: A UK National Survey of Practice. Clin Oncol (R Coll Radiol) 2020; 32:527-536. [PMID: 32216979 DOI: 10.1016/j.clon.2020.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/02/2020] [Accepted: 02/08/2020] [Indexed: 12/25/2022]
Abstract
AIMS The optimal management of stage III non-small cell lung cancer (NSCLC) is widely debated and is a rapidly evolving area. However, less than one in five stage III patients in England receive optimal multimodality treatment. The aim of this study was to map commonalities and differences in clinician judgement as well as infrastructure and resources for managing stage III NSCLC. MATERIALS AND METHODS We carried out a national survey of practice in stage III NSCLC management in the UK using a 30-min web-based survey. Invitations were sent via e-mail to the British Thoracic Oncology Group and the Society of Cardiothoracic Surgery membership and a healthcare professional market research panel. RESULTS In total, 160 respondents completed the survey. Although opinion was variable, there was a preference for surgery and adjuvant chemotherapy in stage III N2 (single station) NSCLC that could be treated with lobectomy, but this preference switched to chemoradiotherapy in single-station N2 requiring a pneumonectomy or multi-station N2. The PD-L1 status influenced the treatment decision in 'potentially resectable' N2 for a number of clinicians who opted for concurrent chemoradiotherapy with adjuvant durvalumab when PD-L1 ≥ 1%. A joint clinic with surgeons and oncologists was considered the most important factor for shared decision making with patients. There are barriers to recommending trimodality treatment, e.g. concerns over the negative impact on quality of life. A proportion of clinicians favoured palliative treatment in certain clinical scenarios, including supraclavicular fossa lymph node metastases, patients with borderline fitness or high PD-L1 expressors >50%. DISCUSSION This survey has highlighted the need for infrastructure development, such as reflex PD-L1 testing and joint surgical and oncology clinics. Further research into the impact of multimodality treatment on quality of life and education to improve confidence in multimodality treatment could all drive improvements in stage III NSCLC management.
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Affiliation(s)
- M Evison
- Manchester Thoracic Oncology Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
| | - J Edwards
- Department of Thoracic Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - F McDonald
- Department of Thoracic Oncology, Royal Marsden Hospital, London, UK
| | - S Popat
- Department of Thoracic Oncology, Royal Marsden Hospital, London, UK
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10
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Putora PM, Leskow P, McDonald F, Batchelor T, Evison M. International guidelines on stage III N2 nonsmall cell lung cancer: surgery or radiotherapy? ERJ Open Res 2020; 6:00159-2019. [PMID: 32083114 PMCID: PMC7024765 DOI: 10.1183/23120541.00159-2019] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 12/12/2019] [Indexed: 12/12/2022] Open
Abstract
Stage III N2 nonsmall cell lung cancer (NSCLC) is a complex disease with poor treatment outcomes. For patients in whom the disease is considered technically resectable, the main treatment options include surgery (with neoadjuvant or adjuvant chemotherapy/neoadjuvant chemoradiotherapy (CRT)) or CRT followed by adjuvant immunotherapy (dependent on programmed death ligand 1 status). As there is no clear evidence demonstrating a survival benefit between these options, patient preference plays an important role. A lack of a consensus definition of resectability of N2 disease adds to the complexity of the decision-making process. We compared 10 international guidelines on the treatment of NSCLC to investigate the recommendations on preoperatively diagnosed stage III N2 NSCLC. This comparison simplified the treatment paths to multimodal therapy based on surgery or radiotherapy (RT). We analysed factors relevant to decision-making within these guidelines. Overall, for nonbulky mediastinal lymph node involvement there was no clear preference between surgery and CRT. With increasing extent of mediastinal nodal disease, a tendency towards multimodal treatment based on RT was identified. In multiple scenarios, surgery or RT-based treatments are feasible and patient involvement in decision-making is critical. For many patients with stage III N2 NSCLC, radiotherapy or surgery are options and should be discussed with the patienthttp://bit.ly/2Z39MW5
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Affiliation(s)
- Paul Martin Putora
- Dept of Radiation Oncology, Kantonsspital St Gallen, St Gallen, Switzerland.,Dept of Radiation Oncology, University of Bern, Bern, Switzerland
| | - Pawel Leskow
- Dept of Thoracic Surgery, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Fiona McDonald
- Dept of Radiotherapy, The Royal Marsden NHS Foundation Trust, London, UK
| | - Tim Batchelor
- Dept of Thoracic Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Matthiew Evison
- Manchester Thoracic Oncology Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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