David Carbone, MD, PHD: Drs Gillaspie and Jabbour, what are the current standard treatment options for patients diagnosed with early-stage lung cancer? Let’s start with the surgical perspective.
Erin A. Gillaspie, MD, MPH, FACS: There’s actually a couple particular trials I’d like to highlight and I think 1 of the key things that I always say when people say early stage, depending on who you ask, we all define that a little bit differently. When I think of early stage, like stage 1 all the way through 3-8, because those people I can operate on. But what I’d actually like to do is a chat, just a tiny bit about the really early stage folks. Historically we’ve always done a lobectomy to treat patients who are diagnosed with lung cancer lobectomy or more. It was all based on a trial that actually came out in 1995 from the Lung Cancer Study Group that looked at lobar versus lobar resections and not only did the sub lobar resections have worse surgical outcomes, had worse oncologic outcomes, it was just a catastrophe. They said lobectomy has to be the gold standard of care.
Fast forward, we start having the analysis data coming out. We have better and better CT [computerized tomography] scans or radiologists are finding earlier and earlier lung nodules. We have everybody getting CT scans for the emergency rooms with tons of people coming in with incidental findings and we’re finding all these sub solid lesions. We’re now doing lobectomy sometimes and finding a 3 mm or 4 mm. Solid component, invasive component. Dr Al-Turki, [MD] and colleagues put this brilliant trial together called CALGB [Cancer and Leukemia Group B] 140503 and what they did is they randomized patients who had tumors 2 centimeters or less with nodes negative. They were tested pathologically intraoperative. We had to take out the nodes. We did take out the tumor, send it to pathology they measured, and we’d call in and find out if we were randomized to low bar versus sub low bar. And sub low bar, I should mention, does include wedge versus segment acting and that’s important to know because obviously there are some differences with lymph node yield between those 2 different surgeries. And actually after 15 years, the study finally finished not only accrual but follow up and they found a few important things. One sub low bar section was noninferior with regards to disease for overall survival and oncologic outcomes were equivalent. Surgical outcomes, there was no increased morbidity with a sub low bar section which is great; length of stay is approximately equivalent. And interestingly they have similar patterns and rates of recurrence and so very similar outcomes for those 2 groups. We see another study being done sort of at the same time CHIGAGO 802, slight differences with that. Their sublevel was just segmented to me but very, very similar findings. We’ve sort of ushered in this new era of so global resections for very small lesions. Now as we start to broaden this and bring it into the real world, it will be really important to continue accumulating data because to me, the most shocking part of this was the 35% recurrence rate for patients during the 7 years of follow up, 35% for node negative tumors that are two centimeters last. I mean, that’s shocking. And that tells me that there’s a huge component of biology that we’re not accounting for. I suspect we’re going to continue to see all of our molecular therapies or immune therapies moving into earlier settings, in particular for these sort of more biologically aggressive tumors.
David Carbone, MD, PHD: Do you tell your patients you’ve got it all?
Erin A. Gillaspie, MD, MPH, FACS:I don’t. I sure don’t, because I think it actually gives them a false sense of security and sometimes that leads them to stop doing follow up. I have a very frank and candid conversation with every single person. Our margins are negative, we’re super pleased with our resection, and we did aggressive lymphatic activity, which is negative, but the most critical piece that we have to do right now for these small tumors is surveillance. I tell them you can make another 1 or you could recur. There’s 2 different scenarios. I say, “Your body, it figured out how to make a cancer. It could do it again.” I think it’s really important for patients to understand that.
David Carbone, MD, PHD: I think too often I hear, “Oh, but my surgeon said, I got it all” and I’m with you. I’m also really hoping that that screening and incidental pulmonary nodule programs will really increase the number of these small nodules that we find since today most patients are diagnosed when they’re not surgically respectable in screening programs, the majority are surgically treatable. You didn’t mention, but also the surgical techniques have…
Read More: Early-Stage NSCLC Standard Treatments