Common clinical practice described for incompletely resected lung cancer

A landmark survey of more than 700 specialists provides crucial real-world insight into the treatments that most oncologists choose for lung cancer patients whose tumor has been incompletely resected.

The study was led by Raffaele Califano, MD, of The Christie NHS Foundation Trust in Manchester, United Kingdom. A total of 768 oncologists from 41 European countries were surveyed about the treatments they offer patients who have “R1-resected” non-small cell lung cancer. R1 resection is a term used by oncologists to indicate that it is possible to find microscopic evidence of cancer cells remaining after a cancer has been surgically removed.

"We know that incomplete resection, or R1 resection, is associated with a higher risk of relapse but there are currently no strong evidence-based recommendations on how to treat these patients after surgery," said Jean Yves Douillard, MD, PhD, from the ICO Institut de Cancerologie de l'Ouest René Gauducheau, France, and Chair of the European Society for Medical Oncology Educational Committee.

"This study is important since it provides a good overview on how the problem is handled in clinical practice all over Europe by practitioners who treat lung cancer," said Douillard. The results were published in Lung Cancer (2014; doi:10.1016/j.lungcan.2014.03.010).

Overall, 83% of experts surveyed were medical oncologists. Of the respondents, 91.4% prescribed chemotherapy, mostly cisplatin/vinorelbine or cisplatin/gemcitabine. The survey showed that the majority of doctors (85%) discussed with the patient the fact that there was limited clinical evidence to guide treatment options. Almost 50% of participants prescribed radiotherapy, with radiation oncologists most likely to offer this treatment approach.

"Treating physicians clearly believe in what they do, and try to provide the best for their patients," said Douillard. "According to the survey, however, practice is heterogeneous and varies according to the specialty of the treating physician—whether they are radiation oncologists or medical oncologists. This is why treatment decisions are best made by multidisciplinary teams."

The evidence gathered in this survey is supported by the recommendations of the 2nd ESMO Consensus Conference on Lung Cancer held in 2013, Douillard noted. That group of worldwide recognized experts recommended adjuvant chemotherapy and adjuvant radiation in R1-resected patients.

The authors of the latest paper called for prospective trials to be undertaken to provide stronger evidence to guide post-surgery treatment in this situation. Douillard agreed that such trials would be informative.

"However, trials of adjuvant treatment in R1 resected lung cancer would be very difficult to design and perform, as this is fortunately an infrequent occurrence. R1 resection would also need to be clearly defined in such studies, as it actually represents a quite heterogeneous group."

"Based on evidence from clinical trials in resected patients in whom all tumor cells have been completely removed, there is a rationale for using both chemotherapy and radiotherapy in R1-resected non-small-cell lung cancer," Douillard said.

"As the authors of this survey state, definitive proof would come from a randomized clinical trial, although such studies would be difficult to perform."

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