Physician preferences for management of patients with stage IIIA NSCLC: impact of bulk of nodal disease on therapy selection

Abstract

Introduction: Stage IIIA non-small cell lung cancer (NSCLC) constitutes a heterogeneous group of patients with predominant ipsilateral mediastinal (N2) disease. The spectrum of lymph node presentation has lead to a host of trials involving various therapeutic combinations, and optimal management has been unclear.

Methods: In 2007 and 2008, 10 live research events surveyed the practice preferences of American medical oncologists using two hypothetical scenarios. The first scenario was of a stage IIIA NSCLC in the right upper lobe with a single enlarged (>1 cm) 4R lymph node found to be malignant by mediastinoscopy. The second was of a bulky stage IIIA NSCLC with multistation N2 pathologically positive nodes.

Results: In the first scenario, 373 (92%) of the oncologists incorporated surgery into their treatment plan. Only 34 (8%) offered chemoradiotherapy alone. Neoadjuvant chemotherapy, followed by surgery and then additional chemoradiotherapy (32%), was the most commonly offered treatment strategy. In the second scenario, 209 (52%) medical oncologists chose definitive chemoradiation. A total of 193 (48%) included surgery as part of the treatment plan.

Conclusions: The current standard of care for IIIA N2 NSCLC recognized before treatment is concurrent chemoradiotherapy. This study demonstrated that a significant proportion of oncologists treating locally advanced lung cancer include surgery as part of the treatment plan more so in single versus multinodal station disease. Since node positive locally advanced disease is such a common presentation for patients with lung cancer, well-designed clinical trials are needed to define the most advantageous treatment strategy for individual subsets of patients with stage IIIA disease.