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Things are changing so fast in lung cancer. I always hypothesized that a shift toward Stage I at diagnosis (and epidemiologically this shift is totally happening) would mean less SBRT (after an initial growth spurt and once and if SBRT tech gets widespread uptake) for rad oncs. And, lo, we are losing steam in Stage III what with immuno and things like LungART. I’m just happy when I get a consult now.
 
TheWallnerus said:
And, lo, we are losing steam in Stage III
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I remain skeptical of the value of surgery in the vast majority of stage III lung CA in the community. My stage III pts are 10 years older than median for Pacific trial. Mediastinal failure remains a problem after surgery and IO helps remarkably with locoregional failure after chemoXRT.

Are we really going to push a 74 y/o (or 68 with marginal lungs) with gross mediastinal adenopathy to surgery with the knowledge of outcomes for concurrent chemoXRT and adjuvant IO? Never mind that these folks grow additional cancers with significant frequency.

We could even apply PIVOT prostate data to this type of insane thinking.

For my money, the two most impressive multimodality IO trials in solid tumors I can think of are Pacific and Checkmate 577 for esophagus. Those are some curves worth looking at.
 
communitydoc13 said:
I remain skeptical of the value of surgery in the vast majority of stage III lung CA in the community. My stage III pts are 10 years older than median for Pacific trial. Mediastinal failure remains a problem after surgery and IO helps remarkably with locoregional failure after chemoXRT.

Are we really going to push a 74 y/o (or 68 with marginal lungs) with gross mediastinal adenopathy to surgery with the knowledge of outcomes for concurrent chemoXRT and adjuvant IO? Never mind that these folks grow additional cancers with significant frequency.

We could even apply PIVOT prostate data to this type of insane thinking.

For my money, the two most impressive multimodality IO trials in solid tumors I can think of are Pacific and Checkmate 577 for esophagus. Those are some curves worth looking at.
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Preop is hot. If this holds up in other sites/studies, xrt could take a hit. I know p value does not reflect effect size, but this is still huge. Will see this trialed in esophagus within 5 years?
 
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I know this is not news and not feasible for all, but tumor boards are helpful for these stage III lungs.

Things I've already seen discussed and had to tell them that this didn't happen in the trial...and I have good med oncs and CT surgeons I work with, but enthusiasm sometimes gets ahead of evidence...:

1. patient's tumor is unresectable, but CT surgeon/med onc want neo to try to convert to resectable. That wasn't a thing on the trial
2. patient has a resectable lung tumor, but a mediastinal node in an area hard to reach/not resectable. It doesn't help us to leave gross disease in there.
3. Keep in mind that reports are now emerging that patient's s/p neoadj chemo/IO that then go on for XRT for whatever reason are showing higher pneumonitis rates. So while I don't think it's crazy to do chemo/IO and then XRT (if surgery is taken off table later)...it's really not ideal.
 
BobbyHeenan said:
I know this is not news and not feasible for all, but tumor boards are helpful for these stage III lungs.

Things I've already seen discussed and had to tell them that this didn't happen in the trial...and I have good med oncs and CT surgeons I work with, but enthusiasm sometimes gets ahead of evidence...:

1. patient's tumor is unresectable, but CT surgeon/med onc want neo to try to convert to resectable. That wasn't a thing on the trial
2. patient has a resectable lung tumor, but a mediastinal node in an area hard to reach/not resectable. It doesn't help us to leave gross disease in there.
3. Keep in mind that reports are now emerging that patient's s/p neoadj chemo/IO that then go on for XRT for whatever reason are showing higher pneumonitis rates. So while I don't think it's crazy to do chemo/IO and then XRT (if surgery is taken off table later)...it's really not ideal.
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Recent stage 3c pdl1 >50% in young pt. Surgey argued why not neoadjuvant then med and proceed to lobectomy if negrative. Not that unreasonable.
 
Are you at a location where your referrals are dependent upon your Medonc's whims?

Then I already know how you will ultimately manage these patients. Checkmate, science.


winning independence day GIF by IFC
 
RickyScott said:
Recent stage 3c pdl1 >50% in young pt. Surgey argued why not neoadjuvant then med and proceed to lobectomy if negrative. Not that unreasonable.
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Yeah, if the primary is especially bulky and nodes that are + are in standard mediastinal dissection procedure, I think surgery makes a lot of sense.

med oncs in my experience more than the surgeons are the ones to be overly enthusiastic about just starting neoadj chemo/IO before thinking it through.
 
@RickyScott I wouldn’t support that off trial. We have no data to support doing that… and level 1 data for CRT->IO. There is no reason to think outcomes would be better with surgery, so why do it?
 
Lamount said:
@RickyScott I wouldn’t support that off trial. We have no data to support doing that… and level 1 data for CRT->IO. There is no reason to think outcomes would be better with surgery, so why do it?
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They didnt ask my opinion. I have no idea if it is better or worse. Wouldn’t surprise me within several years they will be adding and stk11 or some other immune enhancer to the regimen.
 
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RickyScott said:
They didnt ask my opinion. I have no idea if it is better or worse. Wouldn’t surprise me within several years they will be adding and stk11 or some other immune enhancer to the regimen.
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I get the feeling neoadj chemoIO for “unresectable” lung is making thoracic surg “hot” again (their numbers have been pretty stable over last decade… may be getting ready to expand?)
 
TheWallnerus said:
I get the feeling neoadj chemoIO for “unresectable” lung is making thoracic surg “hot” again (their numbers have been pretty stable over last decade… may be getting ready to expand?)
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They can run 5-10.+ trials with cr as endpt in the time it takes us to run one. That alone will sink us. Btw-one thought leader in lung (who we all know well)personally told me (after many drinks) he expects to be largely out of the stage 3 game within 10 years.
 
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RickyScott said:
They can run 5-10.+ trials with cr as endpt in the time it takes us to run one. That alone will sink us. Btw-one thought leader in lung (who we all know well)personally told me (after many drinks) he expects to be largely out of the state 3 game within 10 years.
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Totally practice dependent.... Honestly don't see this becoming widespread in community practice but who knows. The big difference between CT surgery vs ent/urology is that they don't control the flow of patients from diagnosis in my experience. Pulmonary does
 
RickyScott said:
They can run 5-10.+ trials with cr as endpt in the time it takes us to run one. That alone will sink us. Btw-one thought leader in lung (who we all know well)personally told me (after many drinks) he expects to be largely out of the state 3 game within 10 years.
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That’s nonsense, what percentage of IIIa/b patients could even tolerate and or consent to surgical resection, maybe 20% at most 30%?
 
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fiji128 said:
That’s nonsense, what percentage of IIIa/b patients could even tolerate and or constant to surgical resection, maybe 20% at most 30%?
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Thought leaders have to say controversial things so that people continue to listen to them. If his institution is consistently operating on these patients, then it says more about him than it does about the surgeons, who will literally cut everything if given the chance.
 
fiji128 said:
That’s nonsense, what percentage of IIIa/b patients could even tolerate and or constant to surgical resection, maybe 20% at most 30%?
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Last time I was checking on this about 75% of Stage III is managed w/ RT now. Assume 100K new Stage III patients per year. Assume stage shift trends lower this by half over next 10 years and the 75% goes to 50% RT utilization. That means 50,000 less Stage III RT patients per year. Perhaps! (NB: I have no data to back this up but the medical operability rate in lung cancer patients in general should be going up, even in stage III, given the significant changes in stage incidences.)
 
RickyScott said:
They can run 5-10.+ trials with cr as endpt in the time it takes us to run one. That alone will sink us. Btw-one thought leader in lung (who we all know well)personally told me (after many drinks) he expects to be largely out of the stage 3 game within 10 years.
Click to expand...

If only that thought leader would think of doing a Phase III RCT to actually answer the question
 
Well, perhaps he'll be outta the game bc it entails more than circling the white spiky thing and expanding it by 5 mm, and having to manage toxicities. Oh, the luxury of being a thought leader...
 
RickyScott said:
They can run 5-10.+ trials with cr as endpt in the time it takes us to run one. That alone will sink us. Btw-one thought leader in lung (who we all know well)personally told me (after many drinks) he expects to be largely out of the stage 3 game within 10 years.
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Hmmm... I hear the concern, but I don't think this is the case.

The ability to run trials with CR as an endpoint doesn't really help T-surg so much as it helps med onc. Additionally 1 million radiation trials testing various sequencing of chemo, RT and IO, as well as second/third generation IO agents (what are we up to... PACIFIC 10?)

This is not pancreatic cancer where there are no cures without surgery. CRT -> IO works pretty well for LA-NSCLC and is the SOC... surgery is NOT SOC for multi station bulky N2 or N3 NSCLC. For surgery to unseat RT for multi station/bulky N2 or N3 NSCLC, they would need to show superiority in in a Phase III trial, testing chemo-IO -> Surg vs. CRT -> IO... and I don't see that happening anytime soon.
 
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RickyScott said:
by the time it would come out, it would already be outdated by 5 other neoadjuvant pharma trials.
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Are you aware of any Pharma trials trying to convert unresectable to resectable? I am not. Nor is there much of an appetite for this in the cooperative groups.
 
Lamount said:
Are you aware of any Pharma trials trying to convert unresectable to resectable? I am not. Nor is there much of an appetite for this in the cooperative groups.
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It depends what you mean by unresectable. 3c due to nodal involvement, but a small primary is very “resectavle” but traditionally surgey was avoided because the prognosis was poor. When the prognosis changes (pdl1>50 has high cr rate), the role of surgery will change as well.

Surgeons have a different mentality than us. When they start seeing 50% high pdl1+ pts having path cr, a lot of them will jump in and start operating. Minimally invasive lobectomy is not a very morbid procedure- probably less than 60-70 gy of radiation. I recall one survey by chest surgeons where 25% thought they should be the ones giving the immunotherapy.

I think radoncs get too focused on the studies. We can opine all we want on the flaws in a hodgkins study ommitting radiation, but at the end of the day xrt will still go bye-bye in that disease.
 
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RickyScott said:
I think radoncs get too focused on the studies. We can opine all we want on the flaws in a hodgkins study ommitting radiation, but at the end of the day xrt will still go bye-bye in that disease.
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Trial data to your average RadOnc is like garlic to a vampire.

To everyone else in medicine, it's a flavor you can choose to use in a meal, based on the pairing and your personal tastes.

To us...well, you get the idea.
 
elementaryschooleconomics said:
Trial data to your average RadOnc is like garlic to a vampire.

To everyone else in medicine, it's a flavor you can choose to use in a meal, based on the pairing and your personal tastes.

To us...well, you get the idea.
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May have something to do with where you reside in the referral chain.

If you control the patient, you can play fast and loose with the data if not you’re stuck encyclopedically reciting studies down to the subgroup analysis at tumor board just to compel a referral. Jokes on us.

When I was coming up, it was always be the smartest oncologist in the room and people will respect you. Which is pretty much like the old troupe about working hard to make your dreams come true. A lot of it is bull****, some people have the luxury of doing what they want and others have to stick to the letter of the law.
 
Lamount said:
My question to any surgeon convinced that you can turn unressectable to ressectable…

If a CR is really a CR, can’t we just omit surgery? *Ruh Roh*
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Why does this strike me as an “If a tree falls in the forest and no one is around, does it make a sound” question. You can’t really know it’s a CR until you do the surgery, I hear them saying. “Nuke it/operate on it from orbit… it’s the only way to be sure.”
 
TheWallnerus said:
Why does this strike me as an “If a tree falls in the forest and no one is around, does it make a sound” question. You can’t really know it’s a CR until you do the surgery, I hear them saying. “Nuke it/operate on it from orbit… it’s the only way to be sure.”
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You really can’t know it’s ressectable than either 🤔
 
Median age at diagnosis of stage III lung cancer from trials is 65-79 years old.

What is the life expectancy of this group independent of their NSCLCA diagnosis?

At what time point is it likely that OS curves are going to deviate between chemorads then IO vs whatever plus surgery?

We know that the initial survival curves are going to favor the non-surgical approach. They always do.

Surgery in the elderly should be limited to:

1. Procedures that are addressing an imminent threat to life (as in days to weeks): aortic dissection, active CAD, GB on the verge of sepsis

2. Procedure that will immediately improve quality of life: (ortho, TURP).

3. Oncologic procedures where reasonable alternatives are not available (see below).

How sh*%ty is even a chest tube in an elderly patient?

When I think of solid tumors where the evidence for the addition of surgery in terms of OS benefit is nil relative to alternative therapies, I think H&N (exempting OC and salivary), esophagus, cervical and anal CA, prostate and lung cancer.

Surgical disease? Melanoma (XRT helps almost none), colorectal, upper GI exempting gus, sarcoma and endometrial CA.
 
communitydoc13 said:
Median age at diagnosis of stage III lung cancer from trials is 65-79 years old.

What is the life expectancy of this group independent of their NSCLCA diagnosis?

At what time point is it likely that OS curves are going to deviate between chemorads then IO vs whatever plus surgery?

We know that the initial survival curves are going to favor the non-surgical approach. They always do.

Surgery in the elderly should be limited to:

1. Procedures that are addressing an imminent threat to life (as in days to weeks): aortic dissection, active CAD, GB on the verge of sepsis

2. Procedure that will immediately improve quality of life: (ortho, TURP).

3. Oncologic procedures where reasonable alternatives are not available (see below).

How sh*%ty is even a chest tube in an elderly patient?

When I think of solid tumors where the evidence for the addition of surgery in terms of OS benefit is nil relative to alternative therapies, I think H&N (exempting OC and salivary), esophagus, cervical and anal CA, prostate and lung cancer.

Surgical disease? Melanoma (XRT helps almost none), colorectal, upper GI exempting gus, sarcoma and endometrial CA.
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I think I can argue signals for surgery adding to survival in lung and esophagus. Perhaps even prostate. We shouldn’t underestimate how much new targeted immunotherapies are going to change all our “old rules” though.
783D2E27-726E-4B89-89C6-29BFD99FDA15.jpeg
 
TheWallnerus said:
I can argue signals for surgery adding to survival in lung and esophagus. Perhaps even prostate
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There are signals, and the young should be considered for surgery for early stage lung and intermediate (some high risk) prostate cancer, as well as triple modality therapy for esophageal CA.

Competing risks are competing risks however, and 85% of our lung patients are one big competing risk.

Also, what are the targeted therapies and IO doing? What does effective systemic therapy do?

In prostate (I know I keep mentioning this), the best data for local therapy improving survival is in low burden metastatic disease with 55 Gy.

Do we need to surgerize these same patients?

But you and @RickyScott are right about clinical trials and the synergy of surgery and improved systemics in trialists minds.

I'm already seeing my future role in lung CA as treating oligoprogressive stage IV disease.

But, on a population based level, I think this is wrong in the present day. Lots of OR time spent, unnecessary treatment related M&M and rare benefit as we push for more oncologic surgery in the 75+ yo crowd.
 
communitydoc13 said:
There are signals, and the young should be considered for surgery for early stage lung and intermediate (some high risk) prostate cancer, as well as triple modality therapy for esophageal CA.

Competing risks are competing risks however, and 85% of our lung patients are one big competing risk.

Also, what are the targeted therapies and IO doing? What does effective systemic therapy do?

In prostate (I know I keep mentioning this), the best data for local therapy improving survival is in low burden metastatic disease with 55 Gy.

Do we need to surgerize these same patients?

But you and @RickyScott are right about clinical trials and the synergy of surgery and improved systemics in trialists minds.

I'm already seeing my future role in lung CA as treating oligoprogressive stage IV disease.

But, on a population based level, I think this is wrong in the present day. Lots of OR time spent, unnecessary treatment related M&M and rare benefit as we push for more oncologic surgery in the 75+ yo crowd.
Click to expand...

I think we will treat more and more stage I, but not enough to have a significant impact on most clinic volumes. While lung cancer is going down, Americans are aging and more sick, and lung screening is picking up.
 
communitydoc13 said:
Yes, yes, a million of these trials coming down the pipe. But what does the trial say about the value of surgery?
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It says the slope of the line plotting the incidence of using the words “resectable” and “stage III lung cancer” together in the same sentence versus time in oncology is positive.
 
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