VATS vs SABR for Stage I operable NSCLC

[Gfunk6]

Just saw this in Lancet Oncology: Link

Caveats are that it is a single, arm prospective trial and the comparison to surgical arm was based on case-matching, not randomization. But still both arms show overall survival of 91% at three years.

Finally a bit of good news in RO.

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[brushbeamscanning]

I think one critique is that this seems to be a very carefully selected patient population with higher than expected overall survival in both arms.

 

[CaesarRO]

Need VALOR data to come out. It's the Phase 3 data that I'm most optimistic that we'll actually get, and will probably shape this space the most.

I feel like the arguments over STARS/ROSEL pooled analysis did more harm than good with the thoracic surgeons

 

[CaesarRO]

I think one critique is that this seems to be a very carefully selected patient population with higher than expected overall survival in both arms.

Definitely agree with this. The nice thing is that it's matching to a contemporaneous set of surgical pts at the _same_ institution. May not be generalizable to the rest of the country, but even just on its own the SBRT data is great.

 

[Ray D. Ayshun]

Definitely agree with this. The nice thing is that it's matching to a contemporaneous set of surgical pts at the _same_ institution. May not be generalizable to the rest of the country, but even just on its own the SBRT data is great.

I bet in this population in the rest of the country you could expect OS to take a bigger hit in the surgical group as opposed to the SBRT group.

 

[Lamount]

I think one critique is that this seems to be a very carefully selected patient population with higher than expected overall survival in both arms.

Outcomes are certainly better than historical early stage trials, but this could reflect better screening and staging.

As for the population being well selected, I don't disagree. There is certainly a higher likelihood of regional failure with bigger tumors and this trial is <3cm. I would argue that this should move the needle toward SBRT becoming an alternative SOC for operable Stage Ia NSCLC. However, I would leave the T2+ for surgery.

 

[ramsesthenice]

I feel like the arguments over STARS/ROSEL pooled analysis did more harm than good with the thoracic surgeons

You say protest, I say insurrection. People are going to see what they want. Always. I think anything short of a clear survival advantage with radiation in an RCT will do nothing to move the needle with thoracic surgeons.

 

[medgator]

You say protest, I say insurrection. People are going to see what they want. Always. I think anything short of a clear survival advantage with radiation in an RCT will do nothing to move the needle with thoracic surgeons.

I still see plenty of business nonetheless despite that, perhaps it is demographics in the sunbelt with older smokers, lots of fev1 sub 2L pts with terrible DLCOs etc

 

[RickyScott]

If radoncs are sent 25% of 50k stage 1 cases, would work out to a couple per year for each of us?

 

[medgator]

If radoncs are sent 25% of 50k stage 1 cases, would work out to a couple per year for each of us?

Definitely not going to be an equivalent number/RO.... People in California or utah aren't going to see the same numbers per RO as the guy in WV or KY. I treat several lung SBRTs a month, personally

 

[RickyScott]

Definitely not going to be an equivalent number/RO.... People in California or utah aren't going to see the same numbers per RO as the guy in WV or KY. I treat several lung SBRTs a month, personally

Primary stage I?

 

[medgator]

Primary stage I?

Yes. Generally an older population who is either undergoing LDCT screening or had an incidental finding on pre-op/ER chest imaging for another reason. Also get a smattering of oligo lung mets

 

[jondunn]

I do about 5 a month for stage I in community practice

 

[ramsesthenice]

I still see plenty of business nonetheless despite that, perhaps it is demographics in the sunbelt with older smokers, lots of fev1 sub 2L pts with terrible DLCOs etc

We get a lot of those as well. Probably 4-5 per month. But the point GFunk was getting at was specifically for operable patients. I guess I thought the hypothetical question was what kind of data would it take to convince most surgeons that radiation would even be a reasonable alternative to surgery in someone who is healthy enough to choose their treatment. I mean, we already have some indirect data for this. See cancer, prostate.

 

[madchemist89]

I don't see it changing lobectomy vs sbrt much. Perhaps it will reduce the number of wedges (probably not). Most likely it will be ignored and sbrt will continue to be reserved for the most unhealthy of patients.

 

[Lamount]

We get a lot of those as well. Probably 4-5 per month. But the point GFunk was getting at was specifically for operable patients. I guess I thought the hypothetical question was what kind of data would it take to convince most surgeons that radiation would even be a reasonable alternative to surgery in someone who is healthy enough to choose their treatment. I mean, we already have some indirect data for this. See cancer, prostate.

You don’t have to convince surgeons, you have to convince pulmonologists.

 

[thecarbonionangle]

Nobody is as shady as urologists in my book. CT surg is generally alright. I think once it makes it as an equivalent choice for healthy operable patients the game will change.

 

[ramsesthenice]

You don’t have to convince surgeons, you have to convince pulmonologists.

Truth! Where I trained they ruled everything and things were very different. Where I am now, everything lung goes through the surgeons and our guys only get the scraps.

 

[TheWallnerus]

I do about 5 a month for stage I in community practice

Punching well above your weight. You must be in the tobacco belt too.

Even if every Stage I lung in America got SBRT instead of surgery, there would be a little less than one patient per month per rad onc. As is at current referral levels, every rad onc in America has access to about one Stage I per 3 months or so. Of course IRL, patient loads are not normally distributed, averaged among rad oncs, etc. For every high achiever there’s gonna be about 7-10 rad oncs that are like “What’s stage I lung.”

 

[TheWallnerus]

Nobody is as shady as urologists in my book. CT surg is generally alright. I think once it makes it as an equivalent choice for healthy operable patients the game will change.

Urologists will always be about prostate like proton users are about proton data. There’s data, and then there’s the gut. And the gut can’t be wrong because it’s right on top of the prostate. Trust your gut, not data.

 

[communitydoc13]

Even if every Stage I lung in America got SBRT instead of surgery, there would be a little less than one patient per month per rad onc. As is at current referral levels, every rad onc in America has access to about one Stage I per 3 months or so.

I totally believe your numbers but think the distribution of docs/care and typical practice of academic medicine means that the typical "community doc/generalist" probably sees more than this.

I believe we are at point where more than 50% of radoncs in academic medicine. What percentage of a given department will see these lung cases? 20-33%?

I'm not in a particularly large catchment area. Older and above average smoking population (now this will fall through the floor in 10-15 years). About 1 per month per doc in my practice I would say. Maybe a little less.

You don’t have to convince surgeons, you have to convince pulmonologists.

Spot on. The surgeon has to get good results. A few bad outcomes and pulm may change referral patterns.

That old adage about "newly diagnosed early stage lung cancer without treatment has an 18 mos survival" is complete bs in modern era. More low grade adenocarcinomas than anything with incidental pickups/screening. No doubt we overtreat these across the board. Harder to kill someone with SBRT.

 

[TheWallnerus]

I totally believe your numbers but think the distribution of docs/care and typical practice of academic medicine means that the typical "community doc/generalist" probably sees more than this.

I tend to think about these things a lot (too much). I am a community generalist and the last Stage I I saw was more than a year ago. Lung cancer incidence is falling;

I am quite certain I used to see more Stage I >5 years ago. But I don't have hard numbers for that. However we all have hard numbers (thanks, Google) for the number of lung cancers diagnosed per year (~240K), and that ~25% of these will be Stage I. That means 60K Stage I lung cancers per year for the whole country... there's 6000 rad oncs... thus 10 Stage I's per year per rad onc. (And we haven't mentioned how many of these get referred for RT... yet.) One definition of a rare cancer is less than 15 cases per 100K people, and by this definition Stage I lung cancer is a rare cancer in roughly half of all U.S. states (and communities). For example in Utah the annual incidence of Stage I lung cancer is about 7 per 100,000 people. When you factor in that the utilization of RT in Stage I lung cancer is about, at best, 1 in 3 getting RT, then RT for Stage I lung cancer just has to be, mathematically, rare (<15 per 100K) on a nationwide level. In other words, about 33% of the 25% of ~240K lung cancer patients who get Stage I lung cancer per year get RT: that's roughly only 20K people per year getting RT for Stage I lung cancer. Distributed amongst the nation's 6000 rad oncs, that's roughly, at best, 4 Stage I lung cancer patients per year per rad onc.

@jondunn said he's seeing 5 Stage I lung cancers per month. If we "reverse engineer" his numbers using the above math, then for all of us to, on average, achieve what @joedunn does, there would have to be... roughly... 3.6 million lung cancer cases per year, of which 900K would be Stage I, of which 300K per year would be getting referred for RT.

 

[ramsesthenice]

I tend to think about these things a lot (too much). I am a community generalist and the last Stage I I saw was more than a year ago.

Wow. I don't doubt you in any way, I am just shocked. I very rarely treat lung (only when my established GI/GU patients develop a lung cancer we detect incidentally on surveillance imaging...which happens more than I would like). But I cover our community satellites from time to time and we have a joint chart rounds to review their cases every week. They all do at least a couple stage 1 lung cancers per month. Im sure context matters. We live in a relatively rural midwest state. I don't have hard data (but I bet it exists) but in my personal experience (I have a lot family in rural America) smoking cessation in many rural locations seems to lag behind more populated areas. Also, even though our overall population is small, there are not a whole lot of radiation options so our numbers for all tumors/doc are relatively high across the board.

 

[BobbyHeenan]

Yes. Generally an older population who is either undergoing LDCT screening or had an incidental finding on pre-op/ER chest imaging for another reason

This is me.

I practice in a relatively heavy smoking area. Lots of borderline operative candidates and the CT surgeons arent too aggressive so I end up with a lot of stage 1 patients. I send a good amount of lung cases for EBUS too if I get the patient first (some PCP's and med oncs may order CT guided biopsies then send to me) so the Pulm group in return often sends straight to me for the stage 1s they see first.

A lot of the interventional pulm folks know me well, so even sort of "out of town" patients they get funneled into them they will send to me. They know it's a short course of treatment so they don't mind sending a person an hour away from me to me.

So much of the stage I lung volume in my experience is about smoking prevalence, lung CT screening in the community, and pulm. As others have noted, an active pulm group interested in cancer and active at group tumor boards is going to the "gate keeper." That has been true in my practice. The pulm physicians often explicitly say in borderline operative candidates "would not recommend surgery for this, send for SBRT."

 

[BobbyHeenan]

Aside: our group also covers more rural community centers.

Those pulm docs out there don't do nav and have limited EBUS experience. So they will funnel in some cases to the "city" to the interventional pulm who does those procedures. That interventional pulm then will refer to the urban rad onc. So the more rural community rad onc may not be seeing a patient that lives really nearby.

 

[communitydoc13]

20K people per year getting RT for Stage I lung cancer. Distributed amongst the nation's 6000 rad oncs, that's roughly, at best, 4 Stage I lung cancer patients per year per rad onc.

Yeah, I'm just extrapolating from one community practice in one region. A region can consolidate older folks, smokers, etc. while being small in terms of total population.

o much of the stage I lung volume in my experience is about smoking prevalence, lung CT screening in the community, and pulm.

This is our practice. Pulm docs do EBUS and we did have a good community based lung cancer screening program. We briefly had an aggressive thoracic surgeon that cut into our numbers dramatically but I noticed pulm pushing more pts our way after a year or so (even with said doc present) and I'm guessing it was because of their perception of toxicity.

 

[jondunn]

Nobody is as shady as urologists in my book. CT surg is generally alright. I think once it makes it as an equivalent choice for healthy operable patients the game will change.

my experience as well

ENTs and throacic surgery mostly oncologically sounds, interested in trials at a national level, care about data, etc

Urology are bad SEEDS

and not that type of seed!

 

[Gfunk6]

Urology are bad SEEDS

and not that type of seed!

I respectfully disagree. Both are radioactive, can migrate without warning, and after dealing with them you have to carefully check to make sure there is no contamination.

 

[medgator]

This is me.

I practice in a relatively heavy smoking area. Lots of borderline operative candidates and the CT surgeons arent too aggressive so I end up with a lot of stage 1 patients. I send a good amount of lung cases for EBUS too if I get the patient first (some PCP's and med oncs may order CT guided biopsies then send to me) so the Pulm group in return often sends straight to me for the stage 1s they see first.

A lot of the interventional pulm folks know me well, so even sort of "out of town" patients they get funneled into them they will send to me. They know it's a short course of treatment so they don't mind sending a person an hour away from me to me.

So much of the stage I lung volume in my experience is about smoking prevalence, lung CT screening in the community, and pulm. As others have noted, an active pulm group interested in cancer and active at group tumor boards is going to the "gate keeper." That has been true in my practice. The pulm physicians often explicitly say in borderline operative candidates "would not recommend surgery for this, send for SBRT."

I have a pretty good relationship with the CTS and pulm groups in my area and also help run a multiD lung TB bi monthly. End up sending CTS some cases as well where a quick wedge may be both diagnostic and therapeutic rather than trying to muddle around with a non diagnostic ENB or an iatrogenic ptx from the IR guys

 

[jondunn]

ENTs and thoracic surgeons have played ball and run randomized trials in regards to non-operative management

urology has LOW HANGING fruit for a urologist to be famous and run a bladder preservation RCT, like at the VA, and they won't sniff

 

[TheWallnerus]

my experience as well

ENTs and throacic surgery mostly oncologically sounds, interested in trials at a national level, care about data, etc

Urology are bad SEEDS

and not that type of seed!

I respectfully disagree. Both are radioactive, can migrate without warning, and after dealing with them you have to carefully check to make sure there is no contamination.

Lol. And I thought @jondunn meant this sort of seed:

And Onan knew that the offspring would not be his; so it came about that when he went in to his brother’s wife, he wasted his seed on the ground, in order not to give offspring to his brother. (Genesis 38:9)

It's where the word "onanist" comes from (a masturbator). "Wasting your seed" was a sin. It also is a sin to drop a radioactive seed on the ground during prostate brachy.

 

[dieABRdie]

I found at each of the community PP places I practiced at we saw 10 fold more early stage lung cancer for SBRT than I did during residency. Where I trained there wasn't really such a thing as a non-surgical candidate.

Then out of academics I'd have patients referred to me directly by the pulmonologist without ever seeing the thoracic surgeon. I'd mention.... "You know... surgery is the standard of care for this. You should probably talk to a surgeon as well." They would be all confused and say.... "No.... Dr. Pulm said this was the right treatment for me."

"Ok."

Just shows how important the referral pattern is for dictating patient's decisions.

 

[ramsesthenice]

I found at each of the community PP places I practiced at we saw 10 fold more early stage lung cancer for SBRT than I did during residency. Where I trained there wasn't really such a thing as a non-surgical candidate.

Then out of academics I'd have patients referred to me directly by the pulmonologist without ever seeing the thoracic surgeon. I'd mention.... "You know... surgery is the standard of care for this. You should probably talk to a surgeon as well." They would be all confused and say.... "No.... Dr. Pulm said this was the right treatment for me."

"Ok."

Just shows how important the referral pattern is for dictating patient's decisions.

Absolutely. For esophageal cancers I am the point of first contact after endoscopy 9 times out of 10. All the stuff people preach about being available and affable...it really does matter and can help drive local referral patterns.

 

[medgator]

I found at each of the community PP places I practiced at we saw 10 fold more early stage lung cancer for SBRT than I did during residency. Where I trained there wasn't really such a thing as a non-surgical candidate.

Then out of academics I'd have patients referred to me directly by the pulmonologist without ever seeing the thoracic surgeon. I'd mention.... "You know... surgery is the standard of care for this. You should probably talk to a surgeon as well." They would be all confused and say.... "No.... Dr. Pulm said this was the right treatment for me."

"Ok."

Just shows how important the referral pattern is for dictating patient's decisions.

Absolutely. For esophageal cancers I am the point of first contact after endoscopy 9 times out of 10. All the stuff people preach about being available and affable...it really does matter and can help drive local referral patterns.

Seeing a new consult next week with an SPN (solitary pulmonary nodule). Should be enough to get a pet approved and then it'll be off to the races getting them hooked up with pulmonary and CTS

 

[TheWallnerus]

Seeing a new consult next week with an SPN (solitary pulmonary nodule). Should be enough to get a pet approved and then it'll be off to the races getting them hooked up with pulmonary and CTS

Rad oncs get SPN referrals to begin the work up process to refer them for surgery? Intriguing

 

[medgator]

Rad oncs get SPN referrals to begin the work up process to refer them for surgery? Intriguing

A few times a year.... Definitely happens when I'm surveiling pts

 

[TheWallnerus]

A few times a year.... Definitely happens when I'm surveiling pts

I think to Gfunk, original poster’s point, this is good news for rad onc. Yes.

Like if you’re homeless and starving and standing on a street corner and someone gives you ten dollars, that would be good news.

 

[ramsesthenice]

Rad oncs get SPN referrals to begin the work up process to refer them for surgery? Intriguing

I believe it. Like I said, that’s me for esophageal cancers. Why? Because the endoscopists felt like it took too long to get them into see TCV and they got tired of sending them to oncology only to find out they went off script and started induction chemo for T3N0 tumors before anyone else saw them or we even discussed them in TB. If we are the most trustworthy of the bunch we can absolutely find ourselves coordinating and taking the lead on completing the work up etc.

 

[Gfunk6]

I think to Gfunk, original poster’s point, this is good news for rad onc. Yes.

Like if you’re homeless and starving and standing on a street corner and someone gives you ten dollars, that would be good news.

Glass is half full baby

 

[Mandelin Rain]

I believe it. Like I said, that’s me for esophageal cancers. Why? Because the endoscopists felt like it took too long to get them into see TCV and they got tired of sending them to oncology only to find out they went off script and started induction chemo for T3N0 tumors before anyone else saw them or we even discussed them in TB. If we are the most trustworthy of the bunch we can absolutely find ourselves coordinating and taking the lead on completing the work up etc.

Yup.

Instead of "order PET, 2 week follow-up for more workup" that the med oncs do, it's, "PET, EUS (if needed), basic labs, referral to CT surgery, referral to med onc, J tube (if needed), SLP and dietician referrals, return tomorrow for CT sim, add for tumor board, start concurrent next week."

If your system has navigators, they love it if you can lay out the whole workup and plan at once rather than bit-by-bit every 2 weeks. They'll start to direct you referrals before anyone else.

 

[BobbyHeenan]

Yup.

Instead of "order PET, 2 week follow-up for more workup" that the med oncs do, it's, "PET, EUS (if needed), basic labs, referral to CT surgery, referral to med onc, J tube (if needed), SLP and dietician referrals, return tomorrow for CT sim, add for tumor board, start concurrent next week."

If your system has navigators, they love it if you can lay out the whole workup and plan at once rather than bit-by-bit every 2 weeks. They'll start to direct you referrals before anyone else.

Yes! In house nurse navigators helps speed things a long.

your med oncs sound like mine. It's like scan, follow up, refer, follow up, labs, follow up....then we get treatment going . Takes a lot longer for some reason.

 

[communitydoc13]

Instead of "order PET, 2 week follow-up for more workup" that the med oncs do

your med oncs sound like mine. It's like scan, follow up, refer, follow up, labs, follow up

I'm trying to dig into this. I'm learning about medonc clinic scheduling and I believe there is enormous room for streamlining in an integrated community practice.

Often medoncs will see huge number of pts per day, but allocation for new patient consults is not that high (2-3). Chemo-follow-up counts as a follow-up. I'm guessing that there is a fair amount of RVU chasing through clinical scheduling, which is a perverse incentive.

Kind of the opposite of radonc, where the compensation from tx/otv dwarfs any f/u scheduling. We are incentivized to minimized f/u schedule as it is inefficient, poorly compensating (and may not be strongly represented in our contracts). On the other hand, I do think radoncs provide value in follow-up, particularly certain cancers (H&N, stereo lung, anal, DCIS). Some medoncs will have totally superfluous f/ups scheduled for these patients.

 

[jondunn]

I'm trying to dig into this. I'm learning about medonc clinic scheduling and I believe there is enormous room for streamlining in an integrated community practice.

Often medoncs will see huge number of pts per day, but allocation for new patient consults is not that high (2-3). Chemo-follow-up counts as a follow-up. I'm guessing that there is a fair amount of RVU chasing through clinical scheduling, which is a perverse incentive.

Kind of the opposite of radonc, where the compensation from tx/otv dwarfs any f/u scheduling. We are incentivized to minimized f/u schedule as it is inefficient, poorly compensating (and may not be strongly represented in our contracts). On the other hand, I do think radoncs provide value in follow-up, particularly certain cancers (H&N, stereo lung, anal, DCIS). Some medoncs will have totally superfluous f/ups scheduled for these patients.

Hundred percent. Well said. I love your posts

 

[Mandelin Rain]

Yes. I think much/most of med onc pay is on the E&M side. Maybe different if they own the infusion/pharmacy.

 

[medgator]

Yup.

Instead of "order PET, 2 week follow-up for more workup" that the med oncs do, it's, "PET, EUS (if needed), basic labs, referral to CT surgery, referral to med onc, J tube (if needed), SLP and dietician referrals, return tomorrow for CT sim, add for tumor board, start concurrent next week."

If your system has navigators, they love it if you can lay out the whole workup and plan at once rather than bit-by-bit every 2 weeks. They'll start to direct you referrals before anyone else.

J tube??

 

[jondunn]

J tube??

Typically if a patient is going to go to surgery, a J tube is much preferred over a G tube

 

[medgator]

Typically if a patient is going to go to surgery, a J tube is much preferred over a G tube

I know, i usually don't order them in my lung pts however

 

[Mandelin Rain]

I know, i usually don't order them in my lung pts however

I was referencing esophagus case.

 

[ramsesthenice]

I was referencing esophagus case.

I agree if you need a tube J is the way to go, but I almost never place tubes and can't think of a single time I ran into trouble because of it. The other alternative is to place a dobhoff if things go south. Personally, I would NEVER want that for myself and I don't love it. I would take a ppx Jtube over a dobhoff any day of the week. But patients don't know any better and there is just something about the word feeding tube that really rubs some people the wrong way.

Also, FWIW, there is fairly decent data that G-tubes are probably fine for esophageal cancers. This is probably another oncolore hold over that just won't die.

 

[evilbooyaa]

Most Esophagus cases I've seen get through just fine without anything, but this falls more in line with the previous discussion of G-tube for H&Ns - if you can get one done quick, no need to get it PPx. If you can't get it quick without big delays in care, then may be reasonable to get as PPx. But I think we're losing the forest for the trees.

Mandelin Rain meant he multitasks on work-up. Med onc wants to make sure the PET is negative for metastatic disease before getting in for EUS. What I've learned is that you prioritize your big things first (like PET) but get everything else scheduled. If patient is M1 on PET, does he really need the EUS 4 days later? No, but it's easier to cancel then try and schedule an EUS in 4 days.