medwireNews: US researchers say that almost a quarter of people with screen-detected pulmonary nodules receive stereotactic body radiation therapy (SBRT), highlighting the “critical role” radiation oncologists play in the management of these patients.
“The 2022 National Comprehensive Cancer Network Guidelines on Lung Cancer Screening state that chest radiology, pulmonary medicine, and thoracic surgery are the specialties required for a multidisciplinary approach to lung cancer screening without mention of radiation oncologists,” writes Nils Arvold (University of Minnesota Medical School, Duluth, USA) in a commentary linked to the JAMA Network Open research.
“One key implication of this study is that guidelines regarding the multidisciplinary management of pulmonary nodules should be updated to include the involvement of radiation oncologists,” he adds.
The prospective cohort study, by Florence Keane (Massachusetts General Hospital, Boston, USA) and colleagues included data for 1150 patients who were referred to a pulmonary nodule and lung cancer screening clinic (PNLCSC) between 2012 and 2019. The majority (n=916; 79.7%) presented with incidental nodules (≥6 mm) with the remainder (n=234; 20.3%) having chest computed tomography screen-detected nodules (Lung Imaging Reporting and Data System category 4).
Following multidisciplinary review, 196 patients with incidental nodules required treatment, of whom 136 (69.4%) underwent surgery and 60 (30.6%) were given RT. For the 41 patients with screen-detected nodules requiring treatment, 31 (75.6%) underwent surgery and 10 (24.4%) received RT.
In all, 95.7% of the 70 patients requiring RT were treated with SBRT (median dose of 50 Gy in five fractions), including all 10 patients with screen-detected nodules.
Keane and team note that between 2012 and 2014, radiation oncologists were not part of the PNLCSC. During this time the overall resection rate was 20.0% and the overall rate of RT was 1.5%. When radiation oncology joined the multidisciplinary team in 2015, the resection rate in the full cohort decreased to 13.8% by 2019 and the RT rate increased to 6.7%.
In the patients only requiring treatment, the proportion receiving RT rather than resection increased significantly, from 6.9% to 32.7%, once radiation oncologists were included in the clinic, the researchers report.
“These data do not suggest a rogue takeover of a thoracic multidisciplinary clinic by radiation oncologists during the last decade but, instead, illustrate the modern reality of the clinical management of early-stage [non-small-cell lung cancer], wherein up to one-third of patients cannot undergo surgery because of lower pulmonary function, low cardiovascular fitness, and/or advanced age or because they refuse surgery,” says Arvold.
The investigators also observed that the 2-year overall survival rate was 87.1% among the individuals who underwent SBRT, while the 2-year local control and metastasis-free survival rates were 96.2% and 94.3%, respectively.
Therefore, “[s]tereotactic body RT represents a valuable treatment option for patients with screen-detected nodules who are not candidates for surgical resection,” Keane et al remark.
They conclude that their “experience demonstrates the critical role of radiation oncologists in workup and management of pulmonary nodules.”
And Arvold believes: “An updated conception of the multidisciplinary care team could not only benefit patients but also thoracic surgeons, facilitating their selection of the most appropriate patients for surgery and reducing potential pressure to perform resections in borderline cases.”
He concludes that “[d]uring multidisciplinary decision-making, we should ensure that radiation oncologists have a seat at the table.”
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JAMA Netw Open 2022; 5: e224840
JAMA Netw Open 2022; 5: e224849