European Multidisciplinary Conference in Thoracic Oncology (EMCTO 2011) 24—26th February 2011, Lugano
Staging procedures for non-small cell lung cancer
Professor Johan Vansteenkiste (Universitair Ziekenhuis, Leuven, Belgium)
More from ecancer.tv now with Professor Johan Vansteenkiste from Leuven. Johan, you have been talking yesterday, you were chairing a meeting. It is a little bit complicated but it was all about the staging, integration of staging procedures. Now what occurs to me is that this isn’t very easy, did you get any clarification from yesterday’s meeting?
You are right, the patients that do not have metastases, only local or local regional disease, it is quite a heterogeneous group and sometimes treatment decisions are complex and so one of the tools to have good treatment decisions is to start with a good staging of the patient, determining the TNM stage as precisely as possible, also the resectability if the disease is amenable to surgery. And for these decisions nowadays this has really become a multidisciplinary process with input of many disciplines.
Now, in non small cell lung cancer and early and locally advanced disease what things are emerging as key in this staging procedure?
Well certainly with a large randomised controlled trial published last year, one thing that is emerging is that we have improved our imaging methods with CT scan and PET scan, but for verification of the pathology of the disease the endoscopic methods with endoscopic ultrasound, either by the bronchus or the oesophagus, has become very important in our armamentarium. Actually the randomised controlled trial I talk about found that if you start with an endoscopic type of staging and you do only a surgical type in a limited number of patients then you are better off than what we did in the past with the surgical staging only. So it’s an integration of imaging, endoscopy and surgery, and certainly what has moved forward in the last years dramatically is the endoscopic part.
So what sequence of events should there be for the patient presenting?
Well, indeed there was discussion at the session yesterday but many of us now believe that the optimal imaging method is a combination of a PET CT and then you use your endoscopic staging first, and this will be sufficient for many patients. In case of negative findings you should verify by surgical methods, but over all this has really made the staging process more straightforward and less invasive for the patient, and it is a substantial benefit I think.
Now, there are several different categories. Could you summarise what are those key categories and what are the different therapies that would result from the staging conclusions that you come to?
Sure. The main issues are you have patients that don’t have diseased lymph nodes in the mediastinum and on average, if they are fit enough, they go to surgery, straightforward. And then you have patients with lymph nodes in the mediastinum and, to make it a bit simple, there are those with a moderate amount, a more limited amount, of lymph nodes where surgery probably plays an important role in the treatment approach; it will always be multi modality, it will incorporate chemotherapy, surgery, perhaps radiotherapy. And you have others where the lymph node disease is so important that it’s no longer possible to achieve complete resections, and there you don’t need to insert surgery because it doesn’t help, it may actually harm, and so the whole staging process is about dividing these three types: the ones with straightforward surgery, the ones where surgery may play a role in the combined modality setting and the ones where surgery doesn’t play a role.
And to what extent are the newer therapies changing this picture about which treatments you use and how important the staging of the targeted therapies are, for instance?
Well, the new staging methods have brought more detailed, what is often called, mapping of the lymph nodes, where exactly and how important that lymph node’s metastasis in that patient is, and it is by distinguishing these categories that you try to divide the complexity in different treatment: paradigm surgery, only surgery has a role, surgery has no role.
Now, if you get the staging right, can you map out the optimum strategy for each individual patient?
Well, as always with the limitation of medical evidence there is ongoing discussion and discussion usually leads to progress so that is not a real problem; it is good that there is discussion. So a lot of things have been sorted out, for instance for the surgical patients you often add additional chemotherapy after surgery, for the patients that don’t go directly to surgery you use combined modality usually including chemo/surgery, perhaps radiotherapy and you have the non-resectable ones where it is clear that you should give concurrent chemoradiotherapy. So things have been sorted out. What is still a matter of discussion is where are the limits between these categories, between these three categories?
And how much better is the staging and the individualisation of therapy if you use a fully multidisciplinary approach?
Yes, well the word to use is very good. It is individualisation of treatment and I can make the parallel with patients’ metastatic disease, there we try to individualise, based on molecular characteristics. What you do in the patients with non metastatic, with localised, disease, is you try to individualise based on staging and the resectability characteristics. And this is, I think, with all the new tools that we have now, compared to five or ten years ago, where we really can individualise and based on a multidisciplinary board. Because, as you said in the beginning, it is complex, that is why you need the input of a multidisciplinary board, the pulmonologist, the surgeon, radiation oncologist, medical oncologist, an imaging specialist. And yes, I think you can make the difference there for some patients.
And the difference, how big a difference is that likely to be in an ideal world?
Well that is difficult to estimate. I think if you give the same treatment for each of these individuals you will probably stay within a cure rate of 15% in the more advanced local patients. I think if you individualise you can put it to 25-30%.
Those are big figures.
And you are responsible now for the Lugano consensus, so you are one of the big contributors to the Lugano consensus on early and locally advanced non-small cell lung cancer. What is your conclusion?
Well, quite appropriately it is a multidisciplinary group with all the disciplines that I just mentioned. The conclusion is that there are still much controversies and we will try to make a document which makes the best, let’s say the best junction, the best bringing together the medical evidence on the one hand, which is limited, and where there are gaps and a multidisciplinary board experience where you may address some of these gaps. That is what we will try to do.
And in practical terms, finally, what would you like to see doctors doing right now?
What I would like to see is that the more complex cases is that they are always discussed in a multidisciplinary board where all these disciplines are present and probably there is an advantage of people working together there in larger units where their experience is the real live experience on a larger number of patients. And I think that certainly would be a benefit for the patient, having a real multidisciplinary board in an environment where there is large experience.
Johan, thank you very much for being with us on ecancer.tv.