Chest
Treatment of Stage I and II Non-small Cell Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
Section snippets
General Approach
2.1.1. For patients with clinical stage I and II non-small cell lung cancer (NSCLC) and no medical contraindications to operative intervention, surgical resection is recommended (Grade 1B).
2.1.2. For patients with clinical stage I and II NSCLC, it is suggested that they be evaluated by a thoracic surgical oncologist or a multidisciplinary team even if the patients are considered for nonsurgical therapies such as percutaneous ablation or stereotactic body radiation therapy (Grade 2C).
Remark: At
Methods
A multidisciplinary writing committee composed of a pulmonologist, a methodologist, and four thoracic surgeons was assembled and approved according to the process for the ACCP Lung Cancer Guidelines as described by Lewis et al,1 “Methodology for Development of Guidelines for Lung Cancer,” in the ACCP Lung Cancer Guidelines.1 To update previous recommendations on the treatment of stages I and II NSCLC, a series of population, intervention, comparator, outcome (PICO) questions (Table S1) were
General Approach to Stage I and II NSCLC
Surgical resection is widely accepted as the optimal treatment of stage I and II NSCLC over no treatment. There are no RCTs comparing surgery alone to radiotherapy alone, chemotherapy alone, or ablative therapies in otherwise healthy patients with stage I and II NSCLC. The argument for surgery comes primarily from consistent data from retrospective surgical series and databases and registries showing higher survival rates after surgery than after other treatment modalities. Based on such
Minimally Invasive vs Open Surgical Resection
Several recent single-institution retrospective series have demonstrated that VATS lobectomy is associated with fewer complications,41, 42, 43, 44, 45, 46, 47 lower estimated blood loss or transfusion rate,42,48 and shorter hospital LOS,41,44, 45, 46, 47, 48 even for older patients (Figs 5A, 5B).41,42,47,49, 50, 51 Two meta-analyses50,52 (quality assessed as fair and good) and two systematic reviews53,54 (both poor quality) of VATS vs open lobectomy have been reported. These studies all found
Factors to Consider in Interpreting the Data
The standard extent of resection for lung cancer has been lobectomy with systematic lymph node sampling or mediastinal node dissection. Most series reporting the results of sublobar resection (wedge resection or segmentectomy) have no comparison group with lobectomy. Those that had a comparison lobectomy group as identified by our search are summarized in Figure 6.95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110 The table has three sections that group the studies by the
SBRT vs Surgical Resection for Stage 1 NSCLC
Refinements in radiation targeting and delivery have resulted in the development of several different platforms that deliver SBRT for local tumor control. The lung is the most common organ treated with SBRT.139 SBRT differs from standard radiation therapy by delivering shorter, more convenient regimens that involve smaller fields and higher delivered doses to the field. Because SBRT is well tolerated, does not require general anesthesia, and results in minimal damage to surrounding lung, it has
Adjuvant Chemotherapy for Resected Stage I/II NSCLC
6.1.1 Background: A significant number of patients with NSCLC undergoing “curative resection” ultimately die of systemic recurrence, providing continued impetus for development of adjuvant therapies.174,175 To this end, early randomized trials of adjuvant chemotherapy hinted at a beneficial effect of platinum-based therapy, although overall, they did not provide sufficient evidence to support use of adjuvant chemotherapy.176 These trials clearly demonstrated that all chemotherapeutic regimens
Definitions
Determining whether survival for stage I,II NSCLC is meaningfully impacted by ethnicity, geography, and socioeconomic status (SES) is difficult. There are numerous very large registry studies; however, these data are complicated by inherent biases of reporting and lack of sufficient detail. Studies are clearly confounded by the complex interaction of ethnicity, geography, and SES and, given the global nature of the disease, it is impossible to account for all racial and geographic and SES
Conclusion
The treatment of stage I and II NSCLC in good-risk patients is primarily surgical resection. In the seventh edition staging system with size cutoffs for T1a tumors ≤ 2 cm, the application of sublobar resection and nonsurgical therapy is being actively investigated. The role of minimally invasive VATS in the treatment of stage I and II NSCLC has increased since the last edition of guidelines. The best approach to high-risk patients with early-stage lung cancer remains controversial. For patients
Acknowledgments
Author contributions: Dr Howington had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Dr Howington: contributed as the topic editor and oversaw the development of this guideline and contributed to the methodology, staging system, RFA in stage I and II, and thoracic surgeon vs general surgeon sections.
Dr Blum: contributed to the sublobar vs lobar resection and SBRT in stage I and II sections.
Dr Chang:
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Funding/Sponsors: The overall process for the development of these guidelines, including matters pertaining to funding and conflicts of interest, are described in the methodology article.1 The development of this guideline was supported primarily by the American College of Chest Physicians. The lung cancer guidelines conference was supported in part by a grant from the Lung Cancer Research Foundation. The publication and dissemination of the guidelines was supported in part by a 2009 independent educational grant from Boehringer Ingelheim Pharmaceuticals, Inc.
COI Grids reflecting the conflicts of interest that were current as of the date of the conference and voting are posted in the online supplementary materials.
Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://dx.doi.org/10.1378/chest.1435S1.
© 2013 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.