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Review
. 2022 Jun;14(6):2340-2356.
doi: 10.21037/jtd-21-1823.

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 1: a guide to decision-making

Frank C Detterbeck  1 , Justin D Blasberg  1 , Gavitt A Woodard  1 , Roy H Decker  2 , Ulas Kumbasar  3 , Henry S Park  2 , Vincent J Mase Jr  1 , Brett C Bade  4 , Andrew X Li  5 , Whitney S Brandt  6 , David C Madoff  7
Affiliations
Review

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 1: a guide to decision-making

Frank C Detterbeck et al. J Thorac Dis. 2022 Jun.

Abstract

Background: Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options (lobectomy, segmentectomy, wedge, Stereotactic Body Radiotherapy, thermal ablation), weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods: Based on a systematic review from 2000-2021, evidence regarding relevant outcomes was assembled, with attention to aspects of applicability, uncertainty and effect modifiers. A framework was developed to present this information a format that enhances decision-making at the point of care for individual patients.

Results: While patients often cross over several boundaries, the evidence fits into categories of healthy patients, compromised patients, and favorable tumors. In healthy patients with typical (i.e., solid spiculated) lung cancers, the impact on long-term outcomes is the major driver of treatment selection. This is only slightly ameliorated in older patients. In compromised patients increasing frailty accentuates short-term differences and diminishes long-term differences especially when considering non-surgical vs. surgical approaches; nuances of patient selection (technical treatment feasibility, anticipated risk of acute toxicity, delayed toxicity, and long-term outcomes) as well as patient values are increasingly influential. Favorable (less-aggressive) tumors generally have good long-term outcomes regardless of the treatment approach.

Discussion: A framework is provided that organizes the evidence and identifies the major drivers of decision-making for an individual patient. This facilitates blending available evidence and clinical judgment in a flexible, nuanced manner that enhances individualized clinical care.

Keywords: Lung cancer; ablation; decision-making; radiotherapy; surgery.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-21-1823/coif). The series “A Guide for Managing Patients with Stage I NSCLC: Deciding between Lobectomy, Segmentectomy, Wedge, SBRT and Ablation” was commissioned by the editorial office without any funding or sponsorship. FCD served as the unpaid Guest Editor of the series. HSP serves as an unpaid editorial board member of Journal of Thoracic Disease. HSP reports research funding from RefleXion Medical; consulting fees from AstraZeneca; honoraria and speaking fees from Bristol Myers Squibb; and advisory board fees from Galera Therapeutics; all unrelated to current work. BCB reports in the past 36 months, he receives grants from Veterans Affairs Central Office, American Cancer Society, Yale SPORE in Lung Cancer. DCM reports that he is the lead for an early career educational course on microwave ablation that is sponsored by Johnson & Johnson. The authors have no other conflicts of interest to declare.

Figures

Figure 1
Figure 1
General framework for clinical decision-making.
General framework for decision-making about treatment options in individual patients. Qualitative assessment of the impact of treatment approaches on various key outcome measures and the confidence in the evidence. Differences are categorized by degree of clinically meaningful differences (defined in Table S1-1).
Extpol, extrapolation; SBRT, stereotactic body radiotherapy.
Figure 2
Figure 2
Decision guide for healthy patients.
(A) Resection extent; (B) SBRT/ablation vs. VATS surgery. Decision guide for a generally healthy patient with a typical stage I lung cancer. The reference (for improvement or worsening) is the treatment in parentheses.
a, data not parsed by resection extent (segment vs. wedge).
Δ FEV1, change in FEV1 ≥6 months; Abl, ablation (any thermal technique); Conf, confidence in the evidence; FFR, freedom from recurrence (only recurrence counts as an event); LCSS, lung cancer specific survival (only a death due to lung cancer counts as an event); L, lobectomy; LR-FFR, locoregional freedom from recurrence; M/T, margin (distance) to tumor (diameter) ratio; NSCLC, non-small cell lung cancer; OS, overall survival; QOL, quality of life; SBRT, stereotactic body radiotherapy; SL, sublobar resection; Seg, segmentectomy; VATS, video-assisted thoracic surgery; W, wedge.
Figure 3
Figure 3
Decision guide for older patients.
(A) Resection extent; (B) SBRT/ablation vs. VATS surgery. Decision guide for an older patient with a typical stage I lung cancer. The reference (for improvement or worsening) is the treatment in parentheses.
a, data not parsed by resection extent (segment vs. wedge).
Δ FEV1, change in FEV1 ≥6 months; Abl, ablation (any thermal technique); Conf, confidence in the evidence; FFR, freedom from recurrence (only recurrence counts as an event); LCSS, lung cancer specific survival (only a death due to lung cancer counts as an event); L, lobectomy; LR-FFR, locoregional freedom from recurrence; NSCLC, non-small cell lung cancer; OS, overall survival; PS, performance status; QOL, quality of life; SBRT, stereotactic body radiotherapy; SL, sublobar resection; Seg, segmentectomy; VATS, video-assisted thoracic surgery; W, wedge.
Figure 4
Figure 4
Decision guide for compromised patients.
(A) Resection extent; (B) SBRT/ablation vs. VATS surgery. Decision guide for a compromised patient with a typical stage I lung cancer. The reference (for improvement or worsening) is the treatment in parentheses.
a, data not parsed by resection extent (segment vs. wedge).
Δ FEV1, change in FEV1 ≥6 months; Abl, ablation (any thermal technique); Conf, confidence in the evidence; FFR, freedom from recurrence (only recurrence counts as an event); LCSS, lung cancer specific survival (only a death due to lung cancer counts as an event); L, lobectomy; LR-FFR, locoregional freedom from recurrence; NSCLC, non-small cell lung cancer; OS, overall survival; PFT, pulmonary function tests; QOL, quality of life; SBRT, stereotactic body radiotherapy; SL, sublobar resection; Seg, segmentectomy; VATS, video-assisted thoracic surgery; W, wedge.
Figure 5
Figure 5
Decision guide for patients with favorable tumor characteristics.
(A) Resection extent; (B) SBRT/ablation vs. VATS surgery. Decision guide for a patient with a stage I lung cancer with favorable tumor characteristics. The reference (for improvement or worsening) is the treatment in parentheses.
Δ FEV1, change in FEV1 ≥6 months; Abl, ablation (any thermal technique); betw, between; Conf, confidence in the evidence; FFR, freedom from recurrence (only recurrence counts as an event); GG, ground glass; GGN, ground glass nodule; LCSS, lung cancer specific survival (only a death due to lung cancer counts as an event); L or Lobe, lobectomy; LR-FFR, locoregional freedom from recurrence; NSCLC, non-small cell lung cancer; OS, overall survival; PET, positron emission tomography; QOL, quality of life; SBRT, stereotactic body radiotherapy; SL, sublobar resection; Seg, segmentectomy; VATS, video-assisted thoracic surgery; W, wedge.
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