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Robert John Downey

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    PC 01 - 1-1. Surgery vs Non-Surgical Local Treatment for Small-Sized NSCLC (ID 581)

    • Event: WCLC 2017
    • Type: Pros & Cons
    • Track: Early Stage NSCLC
    • Presentations: 1
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      PC 01.02 - Surgery as First Line Treatment Option (ID 7823)

      15:45 - 16:45  |  Presenting Author(s): Robert John Downey

      • Abstract
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      Surgery as First Line Treatment Option for Small-Sized NSCLC Surgical resection has been the preferred standard of care for patients with well established expectations for survival after resection. A standard of care for patients who are deemed medically inoperable is definitive radiation therapy. Because of the proven effectiveness of radiation therapy in treating the medically inoperable patient with lung cancer, consideration is being given to treating medically operable lung cancer patients with definitive radiation therapy instead of surgery. However, recent clinical guidelines issued by ASTRO (Videtic et al) based on a review of the published data include among other recommendations, that ‘For stage I NSCLC patients with anticipated risk of operative mortality of <1.5%, SBRT is not recommended as an alternative to surgery outside of clinical trial settings. The recommended treatment for these patients remains lobectomy with systematic mediastinal lymph node evaluation’. The problem with such recommendations is as follows. The operative morbidity and mortality following pulmonary resection for the overall population of patients undergoing surgery have also been established. The morbidity and mortality in the overall population of patients following definitive radiation therapy is also well documented. What is not available is reliable data on the treatment-related risks faced by subgroups of patients treated with surgery or with definitive chemotherapy who differ in terms of competing risk factor for death, including age (Eguchi et al.) or their overall functional status ((or what is becoming known as the ‘fitness’ or conversely, the ‘frailty’ of a patient) Korc et al)). Emerging data shows that the frailty of a patient affects the likelihood of survival after surgery of diverse types and for diverse diseases. We have found that frail patients undergoing diverse surgeries for diverse malignancies require ICU admission after a given grade of complication at rates far above those required for fit patients (after Grade I complication 0% vs 20%, after Grade 2 complication 6% vs. 17%, and after Grade 3 complication 5% vs. 35% for fit vs. frail respectively) After ICU admission, frail patients remain at a persistent increased risk of death lasting at least to 600 days when compared to fit patients (50% survival vs. 90% survival for frail patients vs. fit patients after ICU care at 600 days) (unpublished data courtesy of Armin Sharokhni, MD). Similar data is not available for patients with NSCLC treated with definitive radiation therapy. Because of this lack of information, objective comparisons of the feasibility and effectiveness of surgical resection with definitive radiation therapy are likely prone to error due to selection biases.A plausible hypothesis is that the population of patients referred for definitive radiation therapy for NSCLC are frailer, and the decreased long-term survival after radiation therapy is due to frailty rather than cancer-related. In this talk, we will review the data available on: 1. Current perioperative morbidity and mortality following lung resections including MIS and sub-lobar procedures 2. Current likelihood of long-term survival following curative lung cancer surgery 3. The competing risks for short- and long-term survival after surgery including age and frailty 4. The methods of risk stratification, including frailty, for a patient being considered for lung cancer surgery 5. The methods of risk stratification that have been used in retrospective and prospective comparisons of surgery and definitive radiation therapy Based on this review, proposals for prospective trials comparing SBRT and surgery for objectively defined medically operable early stage NSCLC will be made. References: Eguchi et al. Impact of Increasing Age on Cause-Specific Mortality and Morbidity in Patients With Stage I Non-Small-Cell Lung Cancer: A Competing Risks Analysis. J Clin Oncol. 2017;35:281-290 Korc-Grodzicki et al. Surgical considerations in older adults with cancer. J Clin Oncol 2014;32:2647-53.. Videtic et al. Stereotactic body radiation therapy for early-stage non-small cell lung cancer: Executive Summary of an ASTRO Evidence-Based Guideline. Practical Radiation Oncology (in press)

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