European Multidisciplinary Conference in Thoracic Oncology (EMCTO) 2013
Treating non-small cell lung cancer with surgery versus SABR
Dr Paul Van Schil – University Hospital of Antwerp, Belgium and Dr Kevin Franks – St James’s Institute of Oncology, Dublin, Ireland
Interviewed by Peter Goodwin
PG: Paul and Kevin, you’ve been discussing at the same session two different aspects of the same problem in treating patients with non-small cell lung cancer, patients who have many comorbidities and are therefore marginal. You’ve been looking at T1b, so early stage non-small cell lung cancer with no metastases and no nodes, what are the kind of decisions made between surgery on the one hand, Paul, and radiotherapy with SABR on the other hand, Kevin? First Paul, well what about the surgery?
PVS: We were talking about functionally marginal patients, meaning the patient has a compromised pulmonary function, sometimes a cardiac function. Then there’s a choice between surgery or radiotherapy. Within surgery there are even several possibilities.
PG: What are the risks in surgery, then?
PVS: The risks in surgery are… it’s not especially the risk of the surgery itself but the comorbidity status from the patient himself. Meaning that you have to cope with more complications after the operation as pneumonia, atelectasis, some cardiac problems, angina, myocardial infarction, so we have to make that clear to the patient and we discuss every patient within a multidisciplinary board.
PG: Of course we now have the fairly new technique of stereotactic radiation so you can actually zap the part of the tumour that’s doing all the harm. What advantages might that have?
KF: Obviously stereotactic radiotherapy is a relatively new technique and even enables us, compared to what we used to do, to improve the chance of local control. It’s now very well established in patients who are clearly not suitable for an operation. So if you’ve got a peripheral tumour it seems to be a very good alternative and a better alternative than conventional radiotherapy.
PG: So if they’re not suitable at all for surgery, then go straight for SABR, you’re saying?
KF: Yes, if it’s in the right location and it’s suitable I think most centres in the world would do that now. The results are very good so the question is it good enough for patients who have got a higher risk from an operation.
PG: And so how do you face up to that sort of risk and what are the considerations you bear in mind?
PVS: We have some specific criteria regarding functional impairment from the European Respiratory Society which were published some time ago. So we follow those criteria and when it’s a marginally operable patient we would discuss with the thoracic oncologist and radiation oncologist whether the patient is suitable for surgery or not. When he is suitable for surgery or the patient agrees to take the risk of surgery then we discuss whether we should do a lobectomy, so take away a lobe of the patient, or what is now called a sublobar resection, so less than a lobe. We know in some instances this is the oncologically correct operation when you have very early stage lung cancer but it does not apply really for T1b cancers. For T1b cancer the preference is still to do a lobectomy, for a lobectomy with lymph node dissection.
PG: And what are the advantages of going straight for surgery rather than considering radiotherapy?
PVS: We know the results of surgery are fairly good regarding oncological treatment so we know that the local recurrence rate after lobectomy with systematic nodal dissection is in fact very low so we can guarantee a good long-term oncological result for our patients.
PG: Can you give me some idea of just how many of your patients are detected at stage T1b?
PVS: Yes, indeed that’s a problem because you can measure the size of the tumours but it’s rather difficult to have a pathological diagnosis before the operation. So when you see a nodule that has an uptake on a PET scan, so the positron emission tomographic scanning, then you’re not quite sure whether it’s really a tumour, especially it could be a tuberculoma, it could be a haematoma, some other diagnoses are possible. So it’s sometimes very difficult to get a precise pathological diagnosis before the operation. Another issue is whether there is lymph node involvement or not and we know that our clinical staging is not reliable for every patient so in some instances we have to do some more invasive staging. So it’s rather challenging to have a precise diagnosis of a T1b N0 non-small cell lung cancer before the operation.
PG: And so you don’t always get it?
PVS: No, we do a frozen section, for example, during the operation, we take it out, we send it to the pathologists to have a more precise diagnosis. And we do the same when there is some doubt about the lymph nodes.
PG: Kevin, when do you think you’re in competition with the surgeons over this situation, then?
KF: I think it’s difficult because often it’s a patient-led choice and we would like to do studies to try and randomise patients between surgery and stereotactic radiotherapy in these very marginal patients and they’ve been tried and hopefully in the UK we’re going to try and do that again to provide patients with a choice because I think it is a patient choice factor. We can all say that surgery has lots of positive points, it has some negative points, and so does stereotactic radiotherapy. I think as a sell to the patients obviously it’s non-invasive, local control rates seem to be equivalent to surgery. On the downside we don’t look at the nodes as much in detail so we may be potentially denying patients some access to treatments such as adjuvant chemotherapy.
PG: And because of the need to get on with treatment do you, from time to time, treat patients and then discover that it wasn’t necessarily exactly T1b N0 M0?
KF: In stereotactic you treat based on clinical findings and radiological findings so there’s always a possibility you may be under-treating patients. Now that doesn’t seem to come out as much in the literature but it’s a real risk and the aim of a randomised study would be trying to prove that risk and define that risk.
PG: Now these relatively early stages of non-small cell lung cancer, that’s where there is a big scope for very good longer term results. How far do you both feel you’ve progressed down that path of improving outcomes for patients?
PVS: I think we’ve totally progressed in that sense, that we have now the minimal invasive resection techniques called VATS, video assisted thoracic surgery. Another point is that in some patients you can also do at the same time what is called a volume reduction so you take away the most diseased parts of the lung. And in some patients you will even improve the lung function after the operation, especially in those patients with an FEV1, so forced expiratory volume in one second, of less than one litre.
PG: And what sort of improvements in outlook are we talking about then in terms of years of survival and quality of life?
PVS: Oncologically those patients have a very good long-term survival but it’s more the comorbidities that will be very difficult for the patient to cope with. Most of those patients will have cardiac problems like myocardial infarction, respiratory insufficiency and so on.
PG: And the advantages from the radiation approach and the improvements recently with this stereotactic technique?
KF: Unfortunately in stage 1 disease it’s still only about one in five patients present with a curable level of stage 1 disease so that’s obviously an area that we need to improve on and that will be improved with early detection, more people getting CT scans. But now that we have options, particularly for patients who are borderline or high risk, that are better that should improve survival and that’s been shown in studies comparing times when stereotactic radiotherapy wasn’t available to where it is now there has been an improvement in survival on the whole population and that’s probably due to the influence of stereotactic radiotherapy along with surgery at the same time. So surgery seems to stay the same but stereotactic radiotherapy seems to be able to treat patients who weren’t treated before, improving survival in those ones and may have a role in the marginally operable patients.
PG: So you’re both actively constructively collaborating; you’re not necessarily in competition. Just a couple of words from each of you about what’s the message we need to remember from all of this?
PVS: I think the main message is when a patient is functionally operable, when he is in good shape, general condition, then the preference is still to do a lobectomy if possible for T1b N0 tumours. On the other hand, when you have a patient that is functionally compromised I think we need more evidence and then you have the options of surgery, sublobar resection or stereotactic radiotherapy. But we really need more evidence from randomised trials and we were just discussing that.
PG: And take home message from radiotherapy?
KF: From our point of view, for the patients who are clearly not operable stereotactic radiotherapy offers a big advantage to those patients and because of that I agree with Paul that we need to do evidence to find out what’s the best option for patients who are in that marginal zone where the surgery may have higher risks and stereotactic may take away some of those risks. We need to know are they equivalent in terms of outcome and long-term outcome.
PG: Thank you both very much.