Management of Patients With Early-Stage Non-Small Cell Lung Cancer: An American College of Chest Physicians Clinical Practice Guideline

Abstract

Background: Lung cancer remains the number 1 cause of cancer death in men and women in the United States and much of the world. This CHEST organization guideline examines the literature on primary treatment of patients with stage I and II non-small cell lung cancer (NSCLC) to provide evidence-based recommendations.

Study design and methods: An expert panel conducted a systematic review addressing the treatment options for patients with stage I/II NSCLC and applied the Grading of Recommendations, Assessment, Development, and Evaluations approach for assessing the certainty of evidence and grading of recommendations. A modified Delphi approach was used to reach consensus on recommendations.

Results: Based on 578 studies, the panel developed 17 recommendations.

Interpretation: The best treatment for average or low operative risk patients with stage I NSCLC remains surgical resection. In patients with stage I NSCLC, a minimally invasive approach is preferred over thoracotomy. For the first time, a meta-analysis comparing overall survival for patients with stage I lung cancer reveals an association between minimally invasive surgery and better patient outcomes. New evidence reveals equivalent overall survival for patients with peripheral ≤ 2 cm NSCLC treated with a sublobar resection compared with lobectomy. To have confidence in the generalizability of these trials, it is important to perform systematic intraoperative mediastinal and hilar lymph node sampling or dissection during operations for patients with stage I and II NSCLC. Use of adjuvant chemotherapy in patients with resected stage II NSCLC plus checkpoint inhibitors, including those patients with ≥ 4 cm, node-negative tumors, improves overall survival. In patients with resected stage IB (≥ 3 cm) and II epidermal growth factor receptor mutant lung cancers, adjuvant targeted therapy improves overall survival. Stereotactic body radiotherapy is the preferred approach to patients with stage I NSCLC who are not considered appropriate candidates for surgical resection.

Keywords: ablative therapy; adjuvant therapy; early-stage; lymph node evaluation; non-small cell lung cancer; stage I non-small cell lung cancer; stage II non-small cell lung cancer; surgical resection; treatment.